Vol 10, No 2, March/April 2002 95 The abundant new technology that has dramatically improved clinical outcomes and quality of life for orthopaedic patients has paradoxi- cally caused patients to view the medical profession less favorably. 1,2 At the heart of this deterioration in the physician-patient relationship is a failure of communication. Among the reasons for this problem are inadequate training of physicians and other health professionals in communication skills, wide varia- tions in patients’ levels of compre- hension, and cultural barriers. Advancing technology also pro- vides increasing amounts of in- formation that might be shared with patients. However, the time for physician-patient interaction is reduced because of the constraints of managed care as well as the trend to provide much medical treatment, including some surg- eries, in the outpatient setting. When hospitalization is required, lengths of stay are short. To ensure the best possible communication with their patients, therefore, physi- cians must understand the charac- teristics and benefits of good com- munication, improve their commu- nication skills, and appreciate the consequences of failing to commu- nicate effectively. Is There A Communication Problem? In 1998, the American Academy of Orthopaedic Surgeons commis- sioned a survey of consumers (patients) to “probe their percep- tions and attitudes towards ortho- paedic surgeons.” 3 Simultaneously, Academy fellows were interviewed to explore their beliefs about the image held of their profession. As a result of this research, the Academy could determine the gap between the image orthopaedic surgeons wished to project and the public’s perceptions. A total of 400 inter- views from a random sample of the public were conducted, followed by a second wave of 407 interviews, for a total consumer base of 807 inter- views. A random sample of 3,500 questionnaires to Academy fellows yielded 700 completed responses. (With these sample sizes, the expected error range is ± 3.6 percentage points.) The results of the survey defined a number of issues. First, orthopae- dists self-rated themselves as good listeners and as caring and compas- sionate (so-called high-touch attrib- utes). However, they were far less charitable in assessing how patients would rate their fellow orthopaedists (Table 1). Second, the patient sam- Dr. Frymoyer is Professor Emeritus, Depart- ment of Orthopaedics and Rehabilitation, and former Dean, University of Vermont, College of Medicine, Burlington, VT. Ms. Frymoyer is Patient Educator and Founder, Community Health Resource Center, Fletcher Allen Healthcare, Burlington. Reprint requests: Dr. Frymoyer, 1450 Braeloch Road, Colchester, VT 05446. Copyright 2002 by the American Academy of Orthopaedic Surgeons. Abstract In the face of rapid advances in technology, there has been a progressive deterio- ration of effective physician-patient communication. The American Academy of Orthopaedic Surgeons has identified that patients rate the orthopaedic profes- sion as high in technical and low in communication skills. Poor communica- tion, especially patient-interviewing skills, has been identified in medical stu- dents as well as in practicing physicians. Effective communication is associated with improved patient and physician satisfaction, better patient compliance, improved health outcomes, better-informed medical decisions, and reduced mal- practice suits, and it likely contributes to reduced costs of care. Recognition of the importance of communication has influenced medical schools to revise cur- ricula and to teach communication skills in residency training and continuing medical education programs. National certifying examinations also are being designed to incorporate these skills. Although written material is useful in increasing awareness of the importance of good physician-patient communica- tion, behavioral change is more likely to occur in a workshop environment. The American Academy of Orthopaedic Surgeons is taking leadership in designing and implementing such an approach for its membership. J Am Acad Orthop Surg 2002;10:95-105 Physician-Patient Communication: A Lost Art? John W. Frymoyer, MD, and Nan P. Frymoyer, MEd ple placed high value not only on technical skills (so-called high-tech attributes) but also on effective lis- tening, care, and compassion—high- touch attributes (Table 2). The com- parison of the orthopaedists’ per- ception of themselves and how patients perceive them reveals a sig- nificant gulf (Table 2). The study also indicates that orthopaedists, compared with primary care physi- cians, are rated as less caring and compassionate and as more techni- cally oriented (Table 3). One appar- ent consequence of these negative patient perceptions is that the respondents rated orthopaedists as giving less value for the cost of ser- vices compared with primary care providers and chiropractors. As a result of this survey, it was recommended that a public rela- tions campaign be initiated that combined a high tech–high touch image of the orthopaedic profes- sion. More specifically, the mes- sage desired by fellows of the Academy is that orthopaedists not only achieve successful medical results and have a high level of training but also combine their technical expertise with a caring and compassionate attitude and lis- ten to their patients. The AAOS also has initiated an education pro- gram in communication, starting with a section of the Bulletin devot- ed to this topic. 4 The results of this survey, and the development of plans to pro- mote effective communication, mir- ror closely steps taken by other professional groups. For example, the American Medical Association has promoted a number of initia- tives to improve physician-patient communication, including a col- umn on the topic in its journal. The Nature of Communication Although definitions of communica- tion “vary in their emphasis on the verbal, nonverbal, content, process, informational, relational, and cultural aspects,” communication clearly is “a transactional process in which messages are filtered through the perceptions, emotions, and experi- ences of those involved.” 5 In the clinical setting, communication is “the process of influencing patient behavior, producing changes in knowledge, attitudes, and skills required to maintain and improve health.” 6 All aspects of the com- munication should be part of the physician-patient interchanges. Communication in the physician- patient relationship usually begins with the initial medical interview. Subsequent encounters in the office Physician-Patient Communication Journal of the American Academy of Orthopaedic Surgeons 96 Table 1 Fellows’ Perception of Self Versus Perception of Orthopaedists in General How Do You Think Top Two Positive How Do You Think Patients Would Rate Responses Patients Would Orthopaedic Surgeons Excellent (5) ‡ (4 and 5) ‡ Describe You? * % in General? † (%) (%) Considerate 91.4 ——— Answers patient’s questions 89.5 ——— Listens to patients 86.1 Listens to patients 6.1 21.3 Spends time with patients 71.3 Spends time with patients 5.5 17.7 Caring and compassionate 71.1 Caring and compassionate 5.8 28.9 Level of medical training 70.4 Level of medical training 20.3 70.7 Successful medical results 64.4 Successful medical results 19.8 89.2 Cost on par with other physicians 64.7 — — — Ease of scheduling an appointment 58.8 Ease of scheduling an appointment 2.7 15.3 Value provided for cost 2.9 33.4 Prestige of specialty 17.1 60.2 Research orientation of specialty 1.5 12.8 Overall 14.5 77.2 * N = 698. Source: survey question 5: Which characteristics do you perceive your patients would use to describe you? † N = 694-698. Source: survey questions 17-26: How do you perceive patients would rate orthopaedists on…? ‡ On a 5-point scale on which 5 = excellent and 1 = poor. Bold type indicates suggested characteristics for emphasis in public relations program. Adapted with permission. 3 or hospital, however, will help to determine the accuracy and com- pleteness of the patient’s story, iden- tify problems, establish the nature and effectiveness of the physician- patient relationship, and serve as a source of patient education. According to Lipkin et al, 7 the medical interview is a core clinical skill for the physician. It and subse- quent interchanges serve three basic functions: gathering information, developing and maintaining a thera- peutic relationship, and counseling the patient and negotiating plans for treatment. Gathering Information The primary goal of the medical interview is to gather as much use- ful information as possible about all John W. Frymoyer, MD, and Nan P. Frymoyer, MEd Vol 10, No 2, March/April 2002 97 Table 2 Attribute Ratings of “Very Important” and Performance Ratings of “Excellent” * Consumer Ratings Important to Important to Attribute of Orthopaedists (%) Consumers (%) Orthopaedists (%) Listens to patients NA 84.7 56.2 Level of medical training 35.2 85.6 70.9 Prestige of specialty 28.3 33.0 NA Research orientation 22.4 38.5 NA Successful medical results 18.4 83.7 88.4 Caring and compassionate 17.7 76.7 63.8 Spending enough time to listen 13.3 73.5 47.8 Ease of scheduling an appointment 12.8 64.6 24.0 Value for cost of service 12.7 70.4 50.2 Physician of choice for musculoskeletal surgery NA NA 75.0 * Source: Consumer survey question 10: “How important is it that your health care professional…?” (N = 807) and fellows’ survey questions 59-67: “Please rate how important it is to have patients associate each of the following characteristics with orthopaedists….” (N = 700). Both based on a 5-point scale on which 5 = very important and 1 = not at all important. Bold type indicates communications messages for public relations program. Reproduced with permission. 3 Table 3 Consumers’ Ratings of “Excellent” * Attribute Orthopaedist (%) Primary Care Physician (%) Chiropractor (%) Podiatrist (%) Overall 20.9 31.3 † 18.0 12.6 † Level of medical training 35.2 36.8 20.7 † 19.3 † Prestige of specialty 28.3 23.2 14.7 † 13.2 † Most knowledgeable in field 27.2 27.2 19.5 † 16.9 † Research orientation 22.4 17.6 16.0 † 11.2 † Successful medical results 18.4 22.9 15.1 11.5 † Caring and compassionate 17.7 34.1 † 24.6 † 14.1 Spending enough time to listen 13.3 31.2 † 25.5 † 12.8 Ease of scheduling an appointment 12.8 27.3 † 28.4 † 13.8 Value for cost of service 12.7 26.1 † 19.9 † 11.4 * Source: Consumer survey questions 6-9: “How would you rate…?” Based on 5-point scale on which 5 = excellent and 1 = poor. † Statistically significant differences from orthopaedist scores. Bold type indicates communications messages for public relations program. Reproduced with permission. 3 of the relevant factors (medical, psychosocial, familial, occupation- al) that will help the physician obtain an accurate diagnosis and develop a comprehensive treat- ment plan. Gathering information requires the following skills: the ability to ask effective questions; accurate observation of data com- municated through verbal and nonverbal cues; addressing and integrating relevant components of the comprehensive medical history; recognizing barriers to effective communication and adapting con- structively to these barriers; and adapting to the diverse beliefs, cul- tural values, and socioeconomic variables of patients and their fam- ily members. 7 It is important in gathering information to use open- ended questions and recognize nonverbal cues. Case Study A 72-year-old woman was seen 2 days after sustaining a comminuted fracture of the distal radius. In dis- cussing treatment options after the interview and examination, the resi- dent and attending physician con- sidered open reduction and internal fixation (ORIF) to be unwarranted in a patient of this age, despite ra- dial shortening. Before outlining the treatment options, however, they asked the patient the open- ended question, “What is the most important thing that we can do for you?” The patient replied with both verbal cues (“Make sure I can keep working on my sculpture”) and nonverbal cues (waving her frac- tured arm). Further questioning revealed that she was an accom- plished sculptor who worked in granite and marble. She made the resident and attending physician aware of the physical requirements of sculpting and convinced them that ORIF was essential to maintain her required level of function. Following surgery, the patient made a complete recovery. Developing and Maintaining a Therapeutic Relationship In developing a therapeutic rela- tionship with the patient, and often with family members, the following skills are necessary to establish trust and mutual respect: treating the patient and the family in a humanis- tic fashion; active listening; recog- nizing emotions and responding empathically to those emotions; rec- ognizing and responding appropri- ately to conflict; and remaining aware of one’s own personal needs, values, and biases while maintain- ing professional integrity. 7 An em- pathic approach can sometimes re- veal the cause of a patient’s concerns that, if otherwise unrecognized, could lead to treatment failure. Case Study A 50-year-old male farmer com- plained of low back pain following heavy lifting 1 month earlier. Dur- ing the interview, the patient report- ed that his family doctor thought his symptoms to be those of a sprain but nevertheless had referred him for radiographs. The radiologists suggested the possibility of a defect in the pars interarticularis and rec- ommended oblique views, but these were negative. A bone scan was unremarkable. Because the patient was still symptomatic, a computed tomography scan was done, which suggested a bulging disk. To con- firm that diagnosis, the family doc- tor ordered a myelogram, which was negative except for clinically insignificant bulging of the L4-5 disk. Serologic tests were negative. The patient then was referred to the orthopaedist, who found no abnor- malities on physical examination, thought the patient to be emotionally depressed, and prescribed physical therapy. Four days later, when the patient was seen because of in- creased back pain, there was no change in his affect or in the physi- cal examination. During the initial interview, the orthopaedist had been overbooked and it was not until the follow-up visit that he took time to learn how emotionally upset the patient and his wife had become. They had put the farm up for auction because the patient did not think he was going to recover. The patient assumed that he must have cancer because “they have done all of these tests and can’t find out what is wrong with me, so it must be cancer.” Un- derstanding these concerns allowed the orthopaedist to reassure the patient and his wife that his discom- fort was not caused by cancer and to give them a detailed explanation of the cause of the symptoms and likely course of recovery. The orthopae- dist also recommended refraining from auctioning the farm. Two weeks later, the patient and his wife reported that he was working full time and that his back pain had notably lessened. Two months later, the patient’s only complaint was mild aching in the low back, a condi- tion he had experienced for years. Counseling and Negotiating With the Patient The third function of physician- patient communication is to impart information to the patient and rele- vant family members that will help them understand the patient’s con- dition, options for treatment, and likely outcome. The important com- ponents are providing effective edu- cation and counseling, motivating changes in behavior, and negotiat- ing treatment plans. 7 Failure to un- derstand a patient’s needs can lead to inadequate counseling, which can adversely affect outcome. Con- versely, understanding a patient’s concerns can lead to effective educa- tion and counseling and positively affect the outcome. Case Study A 48-year-old woman with se- vere osteoarthritis of the right hip Physician-Patient Communication Journal of the American Academy of Orthopaedic Surgeons 98 secondary to congenital dysplasia underwent an uneventful total hip arthroplasty (THA). Six weeks postoperatively, physical examina- tion revealed 90° of flexion and 35° of abduction. She walked well with a cane, and radiographs showed a well-seated THA. However, the pa- tient was depressed and unhappy with the results. More intensive physical therapy was advised; 6 weeks later, her flexion had im- proved to 100° and abduction to 45°, and the patient walked without a limp. Radiographs showed excel- lent prosthetic positioning. Again, however, she indicated dissatisfac- tion with the results and was de- pressed. The patient confirmed for the orthopaedist that the outcomes she had expected, reduced pain and better walking, had been achieved. However, with further questioning she revealed that, because of the osteoarthritis, she had experienced pain preoperatively during sexual intercourse that had created strain in her marriage. In fact, that was her major reason for seeking THA. Postoperatively, no one had told her when she could resume sexual activity, and she was embarrassed to ask. Her husband was threaten- ing to leave her. Sexual counseling was given to the patient and her husband with assurances that she was not at risk to injure herself. Six weeks later, she described her out- come as excellent. The Benefits of Good Communication Good physician-patient communi- cation has been associated with improvements in patient and physi- cian satisfaction, greater compliance with treatment plans, better and more appropriate medical decisions, and reduced malpractice claims. Good communication also likely contributes to improved cost effec- tiveness in providing care. Patient health is more apt to be improved with congruence between patients and physicians in identifying prob- lems and determining course of treatment. 8,9 Stewart 1 reviewed MEDLINE citations from 1983 to 1993 using physician-patient rela- tions as the primary medical subject heading. She concluded that there were positive benefits for good com- munication on emotional health, symptom resolution, function, phy- siologic measures (blood pressure, blood sugar), and pain control. Others have reported similar results, such as more effective management of headaches, hypertension, dia- betes, and peptic ulcer disease, as well as reduced numbers of office visits and reduced hospital lengths of stay. 8-11 Patient and Physician Satisfaction The American Academy on Physician and Patient developed a collaborative study that involved expert analysis of 550 patient audio- tapes recorded during visits to pri- mary care physicians. 12 Patients and physicians were given exit question- naires about the problems they had discussed, the priority of each prob- lem, satisfaction, and patient inten- tion to comply with the physician’s recommendations. Patient satisfac- tion correlated with the patient’s perception of the physician, where- as physician satisfaction correlated with the use of open-ended ques- tions. These findings are consistent with those of other studies. For example, the satisfaction and com- pliance of parents with children treated in the emergency room were greater when the parents could express their concerns. 13 Stiles et al 14 found that the satisfaction of adults in a medical clinic correlated with their ability to talk about ill- ness in their own words. Similarly, eliciting and meeting patient re- quests in psychiatric and family practice clinics are associated with greater satisfaction. 15,16 Stringer et al 17 used 16,230 sur- veys of patient encounters to ana- lyze the office practice of orthopae- dic surgeons. Notable correlations were found between overall patient satisfaction and the following vari- ables: patient understanding of diagnosis and treatment, worker’s compensation status, patient age (older patients were less satisfied), and a wait time >45 minutes. Wom- en approximately 40 years old were most likely to be dissatisfied with the encounter and with office com- munication: their most common complaint was that the orthopaedist talked down to them. Deyo and Diehl 18 found that patient satisfac- tion was greater in patients with low back pain when an adequate, comprehensible explanation was given for the cause of their symp- toms. Compliance With Treatment Plans Transmitting appropriate informa- tion to patients is highly associated with their adherence to a treatment plan. 19 Effective communication is influenced by the amount, complex- ity, and content of the information given and how that information is transmitted. Typically, the physi- cian discusses a recommended treatment with the patient and sometimes supplements the discus- sion with written material and/or videotapes. The patient, however, may or may not be ready to receive information, depending on his or her physical and emotional status. Sometimes the patient may be emo- tionally overwhelmed. Case Study A 38-year-old single mother of two was seen for evaluation of chronic low back pain that intermit- tently had caused her short-term disability. For 6 months she had noted some numbness and pain in John W. Frymoyer, MD, and Nan P. Frymoyer, MEd Vol 10, No 2, March/April 2002 99 the sciatic distribution. The physi- cal examination revealed some loss of sensation in the L5 nerve root dis- tribution bilaterally. Spinal radio- graphs established the presence of a grade II L5-S1 isthmic spondylolis- thesis. Computed tomography con- firmed entrapment of the L5 nerve roots. The surgeon presented the nature of the problem in detail to the patient and discussed both sur- gical and nonsurgical treatment options. One week later, the ortho- paedist was surprised when the patient requested an appointment to learn about her condition and to discuss a treatment plan. At this visit, the woman explained that, during their previous conversation, when the surgeon had mentioned the possibility of surgery, “I thought I would lose my job, and wouldn’t be able to take care of my children. I wasn’t able to listen to you, and ‘tuned out.’” The surgeon had missed the nonverbal cues indicating the woman’s distress. Problems with patient compre- hension and noncompliance extend to the use of reading material. De- spite the widespread availability of patient-directed literature, few or- thopaedists use it routinely. Patients have major variations in reading comprehension, and much material used in health education is beyond the understanding of many pa- tients. 20-22 One analysis of medical illiteracy revealed that 40% of pa- tients were unable to understand written instructions to take medica- tions on an empty stomach. 20 These variations in medical liter- acy are influenced by a patient’s age, primary language, education level, occupation, and cognitive function. Gazmararian et al 22 evaluated 3,260 Medicare enrollees aged ≥65 years: 33.9% of English-speaking and 53.9% of Spanish-speaking respon- dents had inadequate or marginal health literacy. Advancing age was significantly (P < 0.001) correlated with decreasing literacy. Gazmar- arian et al 22 and others 21 have noted that medical illiteracy is associated with substantially worse health sta- tus and poorer outcomes from med- ical treatment. Difficulties in physician-patient interchanges are exacerbated when time for effective communication is inadequate, which is particularly an issue in the managed care setting. Early discharge from the hospital logically necessitates increased patient education regarding matters such as self-care and self-monitor- ing, but the opportunities for com- munication are fewer. Effective strategies include postdischarge tele- phone calls to monitor a patient’s recovery and ascertain the need for more information. 23 Problems in both verbal and writ- ten communication also can arise when a patient requires multidisci- plinary care. Unless there is a well- coordinated team of caregivers, con- flicting information can be given to a patient, or miscommunication among the team members can result in a patient’s not being given the appropriate information. 24 This breakdown in communication can easily occur in orthopaedic surgery, where conflicting information may be given by the surgeon, the physi- cal therapist, and the nurses. One way to avoid such a communication breakdown is for the team to develop a shared plan for the diagnosis and treatment of common conditions, often termed critical pathways. A patient’s need for information and ability to comprehend that information also vary according to his or her recovery. For example, patients who had undergone coro- nary artery bypass reported that they could not assimilate informa- tion in the first 4 or 5 days after surgery, which often was the time when information was given. 25 The analysis also showed wide dis- crepancies between the information physicians and nurses thought the patient needed as well as between the information patients thought they needed and actually received. The results of this study indicate that patient education must be reit- erated and reinforced throughout recovery. Successful communication also includes the involvement of the patient’s family and, as appropriate, close friends, particularly when lan- guage and cultural barriers must be overcome. In such situations, the physician should understand how his or her own psychosocial feelings and beliefs can influence the man- ner in which a patient responds. 26 Case Study A 34-year-old recently immigrated Vietnamese woman complained of knee pain and difficulty moving one leg (her companion served as trans- lator). The physical examination suggested, and magnetic resonance imaging later confirmed, the pres- ence of a torn medial meniscus. An uneventful arthroscopic partial men- iscectomy was performed. One month later, the patient still com- plained of pain and difficulty mov- ing the leg. Aside from stiffness, the physical examination was unre- markable. At the third follow-up visit, the surgeon asked the compan- ion why she thought the patient was taking so long to get better. The companion noted that the patient had not previously had any expo- sure to Western medicine and had relied solely on traditional cures when she had been ill or injured in the past. The patient had not volun- teered this information to the phy- sician, however, because doing so would have been disrespectful. When asked what should be done, the companion suggested using tra- ditional cures simultaneously with the recommended postoperative regimen. The surgeon agreed, and 2 weeks later, the patient’s pain had improved and range of motion was approaching normal. Physician-Patient Communication Journal of the American Academy of Orthopaedic Surgeons 100 An alternative aspect of patient literacy is represented by computer- literate patients. The Internet pro- vides these patients with sources for information other than their physi- cians. Approximately 43% of the 40.6 million adults who accessed the Internet in 1997 did so to obtain medical information. 27 However, the information patients often ob- tain from the Internet is “unfiltered” for content and reliability. Surveys show that computer-literate patients would like to communicate with their physicians by e-mail, but only 1% to 2% of physicians currently offer that service. 27 Appropriate Medical Decisions and Good Outcomes Communication is a major factor both in a patient’s decision to un- dergo surgery and the process of informed consent. Considerable evidence suggests that the consent is not truly informed in many situa- tions because of failures in commu- nication. An analysis of one thou- sand audiotaped physician-patient discussions involving more than 3,500 clinical decisions revealed that fewer than 10% met the study’s cri- terion for informed patient decision- making. 28 Data indicate that more explicit information may reduce the rates of surgery for some types of condi- tions. For example, videotapes have been developed as a mechanism to aid patients in making a well- informed decision. 29 The use of this approach has been associated with significant reductions in surgical procedures. A randomized con- trolled trial 29 compared the use of an informational booklet plus an interactive videotape with use of the booklet alone to inform patients scheduled for lumbar spine decom- pressions. Patients entering the study had either a clinically estab- lished lumbar disk herniation or spinal stenosis. Of the patients with herniated disks, the group that used the videotape chose surgery less fre- quently than did the control (book- let alone) group (32% versus 47%, respectively; P = 0.05 by Kaplan- Meier test). However, of the pa- tients with spinal stenosis, the rate of surgery was higher for the group that used the videotape than it was for the control (booklet alone) group (39% versus 29%, respectively; P = 0.04). The symptoms and functional outcomes were similar at 1 year postoperatively for those who had surgery and those who had not. Although use of the videotapes had no impact on patient satisfaction, those who did view the videotape stated that they were better in- formed. 29 Reduced Risk of Malpractice Suits There is a greater risk of medical malpractice suits with poor physi- cian-patient communication or a breakdown in communication, par- ticularly when complications of treatment have occurred. 30-32 Beck- man et al 30 studied patients’ deposi- tions to determine the causes of mal- practice and found the following causes for lawsuits: deserting the patient (32%), devaluing the pa- tient’s and/or family’s views (29%), delivering information poorly (26%), and failing to understand the pa- tient’s and/or family’s perspectives (13%). Thus, 68% of suits originated in failures of communication. Or- thopaedic surgeons who had better rapport with their patients, who took time to explain the proposed treatment, and who were available to answer questions had fewer mal- practice suits. 31 Primary care physi- cians in Oregon who had received explicit training in physician-patient communication had a reduced rate of malpractice exposure. 33 Cost Effectiveness Improved communication and patient access to information affect hospital utilization and outpatient care. Analysis of readmission rates has shown reductions of up to 50% in cardiac patients when explicit education was given to these pa- tients and reinforced. 34 Similarly, effective preoperative education has been associated with reduced length of hospital stay and fewer complica- tions, as well as with decreased use of narcotic pain medications. 34 All of the advantages of improved communication suggest that cost benefits result from better outcomes, reduced lengths of hospital stay, reduced utilization of office re- sources, and reduced risk of mal- practice suits. To date, however, no study has explicitly quantified any cost benefits attributable to mutually satisfying physician-patient commu- nication. Improving Communication The Status of Effective Communication Skills Despite the importance of com- munication between patients and physicians, development of the skills needed to become an effective communicator is not a core compe- tency stressed in medical, resident, and postgraduate education. Tradi- tionally, the physician-patient rela- tionship has been taught by role modeling: accomplished physicians are observed by students who are expected to emulate the teacher. In a cross-sectional analysis of medical students’ communication skills, Helfer and Ealy 35 found that stu- dents entered medical school with good interpersonal skills and inter- ests but that during the second year, these skills and interests were “flag- ging.” Notable worsening occurred by year 3 of medical school, and by year 4, communication skills were “terrible.” Maguire and Rutter 36 analyzed the nature of student performance of the medical interview. Fifty John W. Frymoyer, MD, and Nan P. Frymoyer, MEd Vol 10, No 2, March/April 2002 101 fourth-year students who had com- pleted all of their major clerkships met with a standardized patient and were asked to complete an inter- view in 15 minutes. The results were as follows: 24% failed to elicit the main problem, 22% did not greet the patient, 12% did not use the patient’s correct name, and 30% failed to give the patient their own names. In all of the domains ana- lyzed, poor or very poor interview- ing competencies were identified in the majority of the interviewers. 36 The absence of effective commu- nication skills extends into practice. Beckman and Frankel 37 evaluated the medical interview in primary care practice settings. Even though open-ended questions are associated with patient satisfaction and with eliciting more information than are closed-ended questions, 37 the aver- age patient was interrupted within 18 seconds of the beginning of the interview. Furthermore, the typical patient had three problems in mind, yet on average only two of the prob- lems were elicited. To determine whether the med- ical encounter in a surgical setting differs from that in primary practice, Levinson and Chaumeton 2 analyzed the quality of the medical encounter in the offices of 39 orthopaedic sur- geons and 27 general surgeons. Audiotapes of 676 encounters were evaluated using a standardized cod- ing system that evaluated four con- ceptual categories: content, process, affect, and social conversation. The mean duration of an orthopaedic visit was 12.7 minutes. Social open- ings were typically brief, with a mean of 45 seconds. The history- taking phase lasted a mean of 3 min- utes 31 seconds, but in 9% of the encounters, the physical examina- tion was started before any history had been taken. Patient education and counseling accounted for almost half the phase (5 minutes 24 sec- onds) and usually was characterized by “relatively lengthy periods of information given by physicians and by brief physician questions.” Less than 10% of the length of the visits was devoted to lifestyle issues, the impact of the condition on the pa- tient’s work, or the patient’s general emotional health. In fact, only 1.3% of the interview times dealt in any way with possible psychosocial issues. 2 Case Study A 58-year-old businesswoman with rheumatoid arthritis was eval- uated for right hip pain. Although the orthopaedist spent time dis- cussing the indications, complica- tions, and likely results of THA, he was pressed for time, and his cur- sory assessment suggested that the patient had no other medical prob- lems. An uneventful THA was per- formed. Postoperatively, however, the patient had notably greater out- put from her drainage tubes than would be expected. When the tubes were pulled 48 hours after surgery, there was increased pain. By post- operative day 4, the patient had pain that did not respond to large doses of morphine. Neurologic examination suggested decreased function of the sciatic nerve. With a presumptive diagnosis of gluteal compartment syndrome, the wound was explored, and more than 1,000 mL of hematoma under pressure was evacuated. The patient’s symp- toms resolved. On closer question- ing, she revealed that she had had abnormal bleeding after two other operations many years earlier but had not thought this was important, nor had anyone asked her explicitly about abnormal bleeding. Further evaluation revealed an unusual de- ficiency in fibrinogen. Teaching Communication Skills The development of effective physician-patient communication skills should start in medical school. Although an explicit curriculum and evaluation of communication skills have been rare in American medical education, in the past de- cade, advances in teaching commu- nication skills have taken place. However, a survey conducted in 1999 by the American Association of Medical Colleges 5 showed that only 5 of the 115 responding schools taught history-taking; the remaining schools used diverse teaching tools (Table 4). Nearly one half of the schools reported that rounds were a common way of teaching communi- cation skills. The report noted that many of these teaching methods were useful but that in the absence of explicit expectations and feed- back as well as precise assessment methods, these methods were likely to have uncertain results (Table 5). In fact, there is a marked discrepancy between the clinician-educator’s communication skills and his or her expectations for students. Cote and Leclere 38 found that the behavior of teachers often did not role model the very behaviors they were seek- ing to reinforce in their students. Teachers often had difficulty de- scribing the interviewing behaviors they hoped to teach their students. An international conference on teaching communication in medi- cine attempted to develop educational tools to improve communication skills in physicians. 39 The partici- pants agreed on eight consensus statements to guide the development of medical school curricula: (1) Teaching and assessment should be based on a broad view of communi- cation in medicine. Teaching should include written and oral skills as well as interprofessional communication and telephone skills. (2) Communi- cation skills teaching and clinical teaching should be consistent and complementary. (3) Teaching should define and help students achieve patient-centered communication tasks. (4) Communication teaching and assessment should foster per- sonal and professional growth. (5) There should be a planned and co- Physician-Patient Communication Journal of the American Academy of Orthopaedic Surgeons 102 herent framework for communica- tion skills teaching. (6) A student’s ability to achieve communication tasks should be assessed directly. (7) Communication skills teaching and assessment programs should be evaluated. (8) Faculty development should be supported and adequately resourced. 39 These broad concepts have been put into operation using some well- studied methods for teaching com- munication skills. Lipkin et al 7 have developed a prototype that involves carefully supervised group discus- sions, encounters with actual pa- tients, role playing, videotapes, con- tinuous feedback, and formal evalu- ation. The goal is to use a workshop approach to focus on skills such as interviewing, knowledge, and physician attitudes. Roter et al 40 uti- lized this workshop model with pri- mary care physicians. An experi- mental group received 8 hours of training. The trained physicians were then compared with untrained physicians in a randomized con- trolled field trial using audiotapes of patient encounters to assess physicians’ skills in problem defini- tion and managing patients’ emo- tional distress. The trained group had markedly greater skills in prob- lem definition, managing emotional distress, counseling, and referral behavior. The results of training were durable when tested at 2 weeks, 3 months, and 6 months. These data strongly support the concept that adult learning occurs optimally in a nonjudgmental work- shop setting. The major impetus that will change medical curricula, however, will come from the inclusion of com- munication skills as part of licensure examinations. The National Board of Medical Examiners has been working on a standardized patient test, part of which will focus on communication as a component of the United States Medical Licensing Examination. 41 The clinical skills tests of the Educational Commission for Foreign Medical Graduates already addresses the effectiveness of physician-patient communica- tion. 42 By linking licensure examina- tions to effective communication skills, greater attention is apt be paid to this area in medical education. Such an approach also is being ex- tended to residency and continuing medical education programs. In some medical specialties, explicit curricula are being developed for residents that ultimately will include John W. Frymoyer, MD, and Nan P. Frymoyer, MEd Vol 10, No 2, March/April 2002 103 Table 4 Methods for Teaching Basic Communication Skills Teaching Methods in Use Schools Reporting (%) * Small group discussions/seminars 91.0 Lectures/presentations 82.0 Student interviews with simulated patients 78.7 Student observations of faculty with actual patients 74.2 Student interviews with actual patients 71.9 Role playing with peers 59.6 Rounds 44.9 Video trigger tapes for discussion 42.7 Videotapes of student interactions 40.4 Instructional videotapes 30.3 Required attendance at community activities 23.6 Journals (ie, written reflections) 19.1 Patient advocacy 13.5 Storytelling by students 13.5 Storytelling by patients (ie, patient narrative) 10.1 * Total number of schools = 89. Reprinted with permission. 5 Table 5 Methods of Assessing Basic Communication Skills Assessment Methods in Use Schools Reporting (%) * Faculty feedback during teaching sessions 92.4 Formalized faculty observation of students 78.3 Patient or simulated patient feedback 76.1 Assessment with simulated patients (ie, OSCE) 69.6 Student self-assessment with videotapes 38.0 Peer assessment 38.0 Multiple-choice examinations 34.8 Formalized feedback from nurses, etc. 23.9 Essay/written examinations 22.8 Student self-assessment without videotapes 20.7 * Total number of schools = 92. OSCE = objective structured clinical examination. Reprinted with permission. 5 evaluation of communication skills in the specialty certifying examina- tions. Similarly, greater emphasis is being placed on communication skills in recertification examinations. Also, because of the impact of poor communication on the quality of medical care, some health mainte- nance organizations are mandating communication training for their staff physicians. What are the Practical Applications for Orthopaedic Surgeons? The American Academy of Ortho- paedic Surgeons’ survey of ortho- paedic surgeons 3 demonstrates that the orthopaedic profession values effective communication. It also is clear that there is a gap between orthopaedists’ self-perception and patients’ perceptions of these com- munication skills. Recognizing that there is a problem is an important first step. A second step is under- way: to further increase awareness through regular feature articles on communications. Effecting true change in behavior will probably require a far more explicit approach, including continued emphasis in medical school curricula on commu- nication, formal residency training in communication, and the opportunity for those in practice to refresh their communication skills. For the prac- ticing physician, the workshop approach appears to be the most effective means to improve these skills. 43-45 A variety of techniques is used, including role-playing, video- tapes of simulated physician-patient encounters, and peer discussions, all elements of successful adult learn- ing. Although the amount of time required to change behavior is a mat- ter of debate, there is consensus that the data support this approach as far more successful than lectures. The American Academy of Orthopaedic Surgeons is a leader in developing workshops to improve communica- tion skills among its members. 46 Such an approach is consistent with the orthopaedic profession’s desire to be seen not only as technically competent but also as vitally con- cerned about our relationship to our patients. Summary Effective physician-patient commu- nication serves three basic functions: gathering information, developing and maintaining a therapeutic rela- tionship, and counseling the patient (including negotiating plans for treatment). Good communication results in several benefits, including patient and physician satisfaction, improved patient compliance, ap- propriate medical decision-making, increased likelihood of good out- come, and reduced risk of malprac- tice suits. Effective physician-patient communication also likely contrib- utes to the cost-effectiveness of care delivery. 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