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Creating a Clinical Model From a Literature Review

Larry B. Mauksch, MEd; David C. Dugdale, MD; Sherry Dodson, MLS; Ronald Epstein, MD

Arch Intern Med. 2008;168(13):1387-1395.

ABSTRACT
Background  While there is consensus about the value of communication skills, many physicians complain that there is not enough time to use these skills. Little is known about how to combine effective relationship development and communication skills with time management to maximize efficiency. Our objective was to examine what physician-patient relationship and communication skills enhance efficiency.

Data Sources  We conducted searches of PubMed, EMBASE, and PsychINFO for the date range January 1973 to October 2006. We reviewed the reference lists of identified publications and the bibliographies of experts in physician-patient communication for additional publications.

Study Selection  From our initial group of citations (n = 1146), we included only studies written in English that reported original data on the use of communication or relationship skills and their effect on time use or visit length. Study inclusion was determined by independent review by 2 authors (L.B.M. and D.C.D.). This yielded 9 publications for our analysis.

Data Extraction  The 2 reviewers independently read and classified the 9 publications and cataloged them by type of study, results, and limitations. Differences were resolved by consensus.

Results  Three domains emerged that may enhance communication efficiency: rapport building, up-front agenda setting, and acknowledging social or emotional clues.

Conclusions  Building on these findings, we offer a model blending the quality-enhancing and time management features of selected communication and relationship skills. There is a need for additional research about communication skills that enhance quality and efficiency.

INTRODUCTION

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Providing high quality care in the time allotted for primary care encounters, irrespective of the visit length, is a major challenge. Most adult primary care patients have 2 or more chronic conditions.^1-2 Estimates of the time required to provide appropriate preventive care (7.5 h/d)³ and chronic illness care (10.5 h/d)⁴ for a panel of 2500 primary care patients suggest that doing an adequate job is difficult. With the addition of the time needed to address acute problems,⁵ complete paperwork, and update medical records, it often seems impossible to perform all of these tasks adequately, and primary care practitioners often feel overwhelmed.^6-7 Therefore, effective communication in primary care must include skills that enhance quality of care while helping patients and physicians use time wisely.

In 2001, an expert panel identified the following specific relationship and communication elements fundamental to all medical encounters⁸:

• Build the relationship: the fundamental task
  
• Open the discussion
  
• Gather information
  
• Understand the patient's perspective
  
• Share information
  
• Reach agreement on problems and plans
  
• Provide closure
  

METHODS

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We searched PubMed, EMBASE, and PsychINFO for the period from January 1973 to October 2006 for descriptive or experimental research written in English that identified quality-enhancing relationship and communication skills that were associated with efficiency during face-to-face encounters between patients and physicians (the live PubMed search is availale at: http://tinyurl.com/3xswfv). We developed 3 inclusion criteria to characterize "efficiency." The identified skill must have: (1) improved quality without increasing visit length, (2) improved quality and decreased visit length, or (3) helped manage time without compromising quality. We then searched for additional reports by the authors of these selected citations or by experts in the field of physician-patient communication. The original searches yielded a total of 1146 citations that we screened (L.B.M. and D.C.D.) to find articles that met our criteria. The 2 reviewers independently read and classified the publications by type of study, research question, outcomes, and limitations. We resolved differences by consensus.

RESULTS

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The available research linking quality-enhancing relationship and communication skills with efficiency is sparse. Only 9 citations met inclusion criteria (Table 1); most others were not original research. We found only 1 experimental study on collaborative agenda setting⁵³ that was conducted by one of the authors (L.B.M.). Its sample size was small, limited to a homogeneous group of physicians in an educational setting, and did not include any direct observation of physician skill use or link the intervention to health outcomes. The remaining studies used observational designs, and most were limited by small sample sizes using a narrowly defined population and did not examine patient and physician satisfaction or health outcomes.

View this table: [in this window] [in a new window] [as a PowerPoint slide]   Table 1. Studies Linking Communication Quality and Efficiency

The 9 articles revealed 3 domains that may be associated with communication and relationship quality and efficiency: rapport building may enhance quality of care without taking more time, while up-front agenda setting and acknowledgment of patients' social and emotional clues may both enhance quality of care and improve time management.

A MODEL OF RELATIONSHIP, COMMUNICATION, AND EFFICIENCY

To create a comprehensive model, we integrated these findings with components that are recognized as essential communication components⁸ plus 1 new component—topic tracking—to enhance efficiency throughout the visit. We cite the literature and explain the relevance of each component in the model. We did not study current, significant influences on communication and efficiency outside of face-to-face interactions between a physician and a patient (eg, previsit agenda forms, e-mail, electronic health records, interactions with other health care providers, or group visits).

In response to a call from the literature,^54-55 we classified skills by the timing of their application during a visit: (1) skills with ongoing influence and (2) skills used sequentially. Four skill sets provide ongoing influence: relationship development and maintenance, mindful practice, topic tracking, and acknowledgment of patient clues. Three skill sets occur in a sequence: up-front, collaborative agenda setting, understanding the patient perspective, and reaching mutual agreement on a plan. The application of the skills at the beginning of the interview creates space for the use of important skills in subsequent interview phases and reduces the chance of using these latter skills in redundant or inefficient ways.⁵⁴ Figure 1 and Figure 2 list communication skills and their quality and efficiency benefits. In the following subsections, we (1) describe each skill; (2) give an example of skill use; (3) name pitfalls of not using each skill; and (4) explain how using each skill avoids pitfalls.

View larger version (56K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 1. Relationship, communication, and efficiency: skills.

View larger version (61K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 2. Relationship, communication, and efficiency: quality and efficiency benefits.

SKILLS WITH ONGOING INFLUENCE

Rapport Building and Relationship Maintenance

Skill Description. A strong physician-patient relationship is essential for effective clinical encounters.⁸ Rapport building such as a warm greeting, eye contact, a brief nonmedical interaction, or checking on an important life event can occur in less than a minute.^49-50

Example. "Nice to see you. "How is your garden this year?" or "How is it to have your son leave home?"

Pitfalls. Patients who feel a poor connection with their physician may have insufficient trust. Conversely, too much small talk may displace time for examining complicated problems.

Avoiding Pitfalls. As relationships develop, physicians can begin each interaction with a brief "check in" to reestablish the relationship. The following skills help maintain a trusting relationship.

Mindful Practice

Skill Description. Mindful practice is characterized by attentive observation of the patient and of the physician's own thought processes to guard against cognitive shortcuts and physician dominance of the agenda.⁵⁶ The mindful physician is present and critically curious⁵⁷ to avoid premature closure.

Example. A physician is concerned that a patient's blood glucose level remains high despite prior interventions. He or she begins to lecture the patient and notices that the patient withdraws. The physician senses a weakening partnership with the patient. The physician realizes that he or she does not know how the patient views diabetes and decides to explore the patient's views.

Pitfalls. The physician who is not present may waste time focusing on issues that are not important to the patient and may miss clues about important thoughts and feelings.

Avoiding Pitfalls. Monitoring one's own preoccupations can enhance the physician's ability to engage the patient in useful problem solving.^58-59

Topic Tracking

Skill Description. Maintaining focus on a mutually agreed on topic is an essential ingredient⁶⁰ in effective psychotherapeutic⁶¹ and behavior change interactions.⁶² In medical visits with multiple topics, discussions are often stopped and restarted as the patient and physician juggle priorities.⁶³ The probability that no clear decision is made on a topic before the close of the visit is inversely proportional to the number of topics in the visit.⁶⁴ The following 3 communication microskills are critical to topic tracking: summarization (sharing one's impression of what has been discussed); process transparency⁶⁵ (describing the interaction); and goal alignment (confirming agreement on the discussion focus).

Example. "Ms Freeman, we decided to talk about your diabetes and it sounds like juggling exercise and diet is hard (summarization). I see that you also want to talk about your back pain (process transparency). I want to make sure that we accomplish something concrete today. Should we stay with your diabetes or shift our focus to back pain and delay dealing with your diabetes?" (goal alignment).

Pitfalls. Physicians who are not aware of "course changes" allow the interview to become disorganized, not completing a topic or rushing through another issue. Physicians, too, may introduce a new topic without an agreement at the beginning of the encounter.

Avoiding Pitfalls. The physician must monitor the discussion as if observing it from the outside. It may or may not be appropriate to adjust the agenda when new issues emerge. If physicians share their reasoning for time use adjustments, patients may be more engaged.⁶⁶

Acknowledging Social or Emotional Clues With Empathy

Skill Description. Clues surface in any phase of the interview and signify thoughts or feelings contributing to patient behavior or illness. Empathic acknowledgment of clues may move the patient to reveal beliefs about illness and treatment preferences that can facilitate creating an effective plan. Providing empathy is intentional^67-68 and teachable.^69-70 It may promote patient self-efficacy without extending visit length.^71-72 Empathy can be used to focus discussions or to invite further exploration. Acknowledging clues may shorten visits perhaps because there is a decreased need for patients to restate their concerns.²⁴

Examples. (1) Clue acknowledgment to focus a discussion—"It is frustrating when your asthma prevents you from getting to work," followed by, "Let's see how we can improve your symptoms and your ability to keep your job." Empathic acknowledgment decreases risk of the patient feeling discounted and improves the quality of care.^72-74 (2) Clue acknowledgment to invite further exploration—"Even though the test results were normal, you still seem concerned this may be cancer. Can you tell me more?"

Pitfalls. Missing clues may hinder understanding the patient's core concern.^75-76

Avoiding Pitfalls. When used judiciously, verbal and nonverbal expression of empathy can be very brief (1-10 seconds) while still conveying an appreciation of the patient's suffering.

SKILLS USED SEQUENTIALLY

Up-front, Collaborative Agenda Setting

Skill Description. Primary care physicians are generally presented with 3 to 6 concerns per visit^{18, 63, 77} and frequently more. It is not possible to address all concerns in detail in every visit. After initially checking in with the patient, the physician and patient can collaboratively create an agenda for the visit.⁵³ Up-front, collaborative agenda setting is more thorough and efficient than the more common approach of addressing each issue as it surfaces.^21-22,78 When physicians know the number, urgency, and importance of all the patient's concerns, they will be more likely to address them, and they are also able to make rapid judgments about their time needs.⁷⁹ Up-front agenda setting allows the physician and the patient to prioritize and explore the most important concerns⁴⁵ and decrease the probability of "Oh, by the way" issues surfacing at the end of the visit.^{21, 51-52} The physician explains that creating a list of concerns will help determine how to make the best use of time. Diagnostic questioning is postponed. The physician uses repeated prompts to help the patient name additional concerns. Next, the physician confirms which problem is most important to the patient.⁸⁰ If necessary, the physician negotiates with the patient to protect time for urgent medical problems and postpone some issues for subsequent visits.

Example. "Let's figure out how to make the best use of our time." "What concerns would you like to address today?" Or in follow-up visits, "We planned to discuss your diabetes but I want to check if something else is a concern to you today?" Then, "something⁸¹ else?" and "Do you need any prescriptions refilled or paperwork filled out?" If the patient elaborates on a concern before listing other concerns, the physician might say, "Your headaches sound painful but before we go further, was there something else you hoped to address today?" And eventually, "Am I correct that your headaches are most important? How about if we begin with your headaches and save some time to check on the diabetes?"

Pitfalls. It is tempting to explore the first topic raised in the visit.²² Conversely, a physician who rigidly pursues agenda setting may compromise patient satisfaction⁸² by forgetting to make a connection or missing patient clues about emotionally laden issues.

Avoiding Pitfalls. When the patient's emotional clues reveal the patient's need to tell a story, the physician should listen. If not interrupted, the great majority of patients will talk less than 2 minutes.⁸³ To contain patients who spend excessive time talking, use the skills described in the subsections on "Topic Tracking" and "Acknowledging Clues." Spending more time on a complex issue may be a better use of time than skipping from one problem to another without first considering patient motivation and problem complexity.⁸⁴ Follow-up visits may provide further opportunities to explore other issues in depth.

Exploring the Patient's Perspective

Skill Description. Once the agenda is defined, 2 forms of information gathering are woven together: diagnostic investigations and understanding the patient perspective. Explore the patient's perspective when (1) promoting self-management⁸⁵; (2) examining health behavior change⁶²; (3) the patient gives clues about underlying thoughts and feelings^{75, 86}; (4) family⁸⁷ or cultural⁸⁸ factors influence patient beliefs and behavior; (5) psychosocial problems diminish patient function⁸⁹; and (6) symptoms are medically unexplained.^90-91 These explorations can be done without increasing visit length⁹² and may reduce patient anxiety, identify knowledge gaps, and improve adherence and outcomes.⁹³ Indeed, curious⁵⁷ listening may be central to the "healing"⁹⁴ experience.

Examples."What do you know about diabetes?" "I know that food plays an important role in your life. Tell me about it." "What would your physicians in Russia have done for this problem?"

Pitfalls. The exploration of the patient's perspective may be impeded by not allocating time during agenda setting. Ignoring the patient's beliefs may lead the physician to create a plan with little chance of success.⁹⁵

Avoiding Pitfalls. Thirty seconds to 5 minutes⁸⁶ is usually enough time to understand patient beliefs and behavior and assess motivation for self-management. Understanding the patient's perspective may reduce wasted time delivering rote, off-target educational monologues. Several interview models have been developed to explore patient,⁹⁶ family,⁸⁷ and cultural⁹⁷ perspectives.

Cocreating a Plan

Skill Description. Complicated problems may benefit from more time devoted to shared and informed decision making.¹⁸ When patients are involved in plan creation, they are more satisfied and have better outcomes and their physicians are less likely to generate unnecessary tests or referrals.^12-13,40 Physician documentation of agreement with patients on problems needing follow-up is associated with increased problem resolution by the next visit.^98-99 Patients are more likely to adhere to plans if patients perceive that the plan accommodates their financial and social resources.¹⁰⁰ Clinicians should also tailor recommendations to patients' readiness to change.¹⁰¹ The planning phase concludes with explicit agreement on the goals of care, next steps, and the roles of the patient, family members, and clinicians in implementing the plan.

Example. "I think we agree that something needs to be done about your rising blood glucose levels. In reviewing the options, you would like to first try diet change and increase your exercise. These choices are not easy to implement and maintain. Lets create a plan to support you in this effort. Does this make sense?"

Pitfalls. Forgetting to set an agenda, not using topic tracking skills or not pursuing an understanding of the patient’s perspective increases the risk of offering a plan misaligned with patient preferences¹⁰² and increasing resistance to self-management.¹⁰³

Avoiding Pitfalls. Physicians must save time for cocreating a plan and explain why addressing fewer problems in greater depth may do a better job.¹⁰²

CONTRASTING EFFICIENT AND INEFFICIENT INTERACTIONS

Table 2 gives a model in which the poles of the vertical axis are high-quality, efficient communication (top) and low-quality, inefficient communication (bottom). The poles of the horizontal axis are "feeling pressed for time" (left side) and "feeling there is enough time" (right side). We emphasize perception instead of naming absolute visit lengths because physician perception influences how time is used.¹⁰² Several factors may affect perception beyond appointment length such as whether one is behind schedule, one's understanding of patient needs, and one's sense of competence.^{79, 104} The communication behaviors in the 2 high-quality, efficient quadrants include shared decision making about interview content, illness models,⁹³ and treatment plans. The organizational structure and process of the visit is transparent. These behaviors are not present in low-quality, inefficient interactions.

View this table: [in this window] [in a new window] [as a PowerPoint slide]   Table 2. Contrasting Efficient and Inefficient Interactions

COMMENT

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While evidence from several countries suggests that high-quality communication can occur between patients and physicians during interviews of variable lengths, our knowledge about how this is accomplished is limited. Rapport building, up-front collaborative agenda setting, and acknowledging social and emotional concerns may help improve quality of care and efficiency. We blended these skills into a comprehensive model to help physicians make the best use of time throughout the visit. Our review did not analyze important quality-enhancing encounters with other health care team members. The use of these skills in face-to-face encounters creates trust and understanding that may increase the willingness of patients to work with an expanded health care team¹⁰⁵ in person or via telephone or e-mail. Future studies of physician-patient communication require effective training designs¹⁰⁶ and should combine qualitative and quantitative methods to examine the relationships between physician behaviors, time use, patient and physician satisfaction, resource use, and health outcomes.^107-108

AUTHOR INFORMATION

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Correspondence: Larry B. Mauksch, MEd, Department of Family Medicine, University of Washington, 4245 Roosevelt Way NE, Box 354775, Seattle, WA 98105 (mauksch{at}u.washington.edu).

Accepted for Publication: January 13, 2008.

Author Contributions: Study concept and design: Mauksch, Dugdale, and Epstein. Acquisition of data: Mauksch, Dugdale, Dodson, and Epstein. Analysis and interpretation of data: Mauksch, Dugdale, and Epstein. Drafting of the manuscript: Mauksch, Dugdale, and Epstein. Critical revision of the manuscript for important intellectual content: Mauksch, Dugdale, Dodson, and Epstein. Obtained funding: Mauksch. Administrative, technical, and material support: Mauksch, Dugdale, and Dodson. Study supervision: Mauksch, Dugdale, and Epstein.

Financial Disclosure: Mr Mauksch receives honoraria and consultation fees from health care organizations for teaching communication skills to health care providers. Dr Epstein gave a Web lecture in 2007 on physician-patient communication sponsored by Merck Pharmaceuticals.

Funding/Support: Portions of this work were supported by grant R01 HS13172_01 from the Agency for Health Research and Quality and by the Arthur Vining Davis Foundations Paired Observation and Video Editing education model (Mr Mauksch).

Previous Presentations: During the process of developing these ideas, portions of this work were presented to medical education audiences including medical educators, medical students, residents, and practicing physicians. An example of some of these presentations include the following: Annual Update in Family Practice and Primary Care, September 2006, University of Washington, Seattle; University of Washington Family Medicine Residency, October 2006-2008, Seattle; Faculty Training, Paired Observation and Video Editing Project, March 2007, University of Washington, Seattle; and Annual Scientific Assembly, Washington Academy of Family Physicians, May 2007, Pasco.

Additional Contributions: Daniel Cherkin, PhD, Stuart Farber, MD, Eric Larson, MD, MPH, and Valerie Ross, MS, provided thoughtful comments on the model and this manuscript, and Claire Mauksch provided editing assistance.

Additional Information: MeSH terms and search strategy are available from the corresponding author on request.

Author Affiliations: Departments of Family Medicine (Mr Mauksch) and Medicine (Dr Dugdale) and Health Sciences Libraries (Ms Dodson), University of Washington, Seattle; and Departments of Family Medicine, Psychiatry, and Oncology, University of Rochester School of Medicine and Dentistry (Dr Epstein) Rochester, New York.

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