Communication Issues in Healthcare: Its Relation to Malpractice Risk, and How to Communicate More Effectively
Continuing Medical Education Overview: This article will discuss the issue of communication in healthcare and how it can lead to errors, or conversely improve care. It will cover how communication behaviors are related to malpractice risk. There will also be some suggestions on how to improve communication skills.
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by Stuart M. Caplen, MD
Malpractice and Communication
It has been reported that communication issues were a factor in 30% of malpractice cases filed from 2009–2013. Those 7,149 cases resulted in a reported 1.7 billion dollars of malpractice costs. Eight percent of communication failures which led to litigation were in the emergency department, 44% were from inpatient settings and 48% from outpatient settings. There was some overlap of communication issues leading to malpractice cases, but 57% involved provider-to-provider issues and 55% were provider-to-patient communication problems.[1,2]
The Problematic Patient Handoff and Change of Shift
Joint Commission data indicate that inadequate patient handoffs are a factor in 80% of all adverse events.[2]
A survey of medical schools found only 8% taught students how to properly handoff patients.[3] In one study, 59% percent of residents at Massachusetts General Hospital reported that one or more patients had been harmed during their most recent clinical rotation because of problematic handoffs, and 12% reported that the harm had been major.[4]
The Joint Commission, in order to try to reduce errors in patient handoffs requires the use of standardized methods, forms, or tools to facilitate the process. One such method, a hand-off checklist of critical information, is called “I PASS the BATON” was developed by the U.S. Agency for Healthcare Research and Quality.[2]
I PASS the BATON[2]
I = Introduction—Introduce yourself and your role/job (include patient).
P = Patient—Name, identifiers, age, gender, and location
A = Assessment—Presenting chief complaint, vital signs, symptoms, and diagnosis
S = Situation—Current status/circumstances, including code status, level of uncertainty, recent changes, and response to treatment
S = Safety Concerns—Critical lab values/reports, socio-economic factors, allergies and alerts (falls, isolation, and so on)
[the]
B = Background—Comorbidities, previous episodes, current medications and family history
A = Actions—What actions were taken or are required? Provide brief rationale.
T = Timing—Level of urgency and explicit timing and prioritization of actions
O = Ownership—Who is responsible (nurse/doctor/team)? Include patient/family responsibilities.
N = Next—What will happen next? Anticipated changes? What is the plan? Are there contingency plans?
Physician Communication Behaviors and Malpractice
An experiment was performed to determine how communication behaviors might influence the decision of a patient to pursue a malpractice case. Participants were shown different videos, one of a patient being examined by a physician with good communication behaviors such as good eye contact, friendly tone of voice, and requesting information. The other video was a physician using negative communication behaviors such as poor eye contact, harsh and clipped tones of voice, nonsmiling expressions, and minimal requests for information. The participants were then told several different possible outcomes of the patient’s disease process. If the outcome was negative, it was reported that the participants were significantly more likely to blame the negative communication behavior physician, felt that the physician was negligent and wished to sue that physician as compared to the good communication behavior physician. Even if the outcome of the patient’s disease process was a favorable one, the subjects felt the poor communication physicians were more negligent. They also rated the poor communicators as less professional, less caring, less friendly, less trustworthy, less competent, and significantly more negligent and liable for a poor result. Interestingly, the authors were concerned about whether the negative behaviors the physician actors used in the simulations were unrealistic and overly excessive. They asked the participants about that and in some cases were told “Well, that's just the way they are”.[5]
Interruptions and the High Control Interview Style
In a 1984 study it was reported that 77% of patients were not able to complete their opening statements of concern or chief complaint. Most interruptions, 54%, occurred after the first expressed concern and occurred on average 18 seconds after the patient began to speak. In 69% of the visits the physician interrupted and started directing questions toward the chief complaint and only one of 51 patients was given the opportunity to complete their opening statement by the physician after interrupting.[6]
One might hope physician communication behaviors had improved over time, but in 2004, an emergency department study of residents reported that only 20% of patients completed their presenting complaint without interruption. The average time to interruption was 12 seconds. On discharge, only 16% of patients were asked whether they had questions, and there were zero cases in which the provider confirmed patient understanding of the information. About one third of the residents never introduced themselves to the patient.[7]
This process, whereby the physician takes control of the interaction by asking questions, and in many cases not allowing the patient to even complete their opening statement, is known as the high control interview style. This can be problematic, as one study found that 24% of the time for somatic problems and 94% of the time for psychosocial problems, the chief complaint was not actually the patient’s most significant problem, and potentially a cause of diagnostic error.[8] An example of this might be where a patient’s first complaint is of vomiting at which time the physician interrupts and starts asking abdominal specific questions. By not allowing the patient to expound further, the clinician might not discover that the vomiting was secondary to a subarachnoid hemorrhage or an acute glaucoma attack.
Other Physician Communication Issues
A study from the 1980s clearly demonstrated some physician communication issues. It reported that doctors spent an average time of slightly more than 1 minute out of a 20-minute encounter giving information to their patients. However, on asking the doctors how much time they spent giving their patients information, the doctors overestimated that time by about a factor of nine. They thought they had spent much more time informing their patients than they actually did.[9]
Nonverbal Communication and Vocal Tone
Nonverbal communication using body language and vocal tone may be as important or even more important than the words that are actually spoken. Early research in the subject determined that when there are inconsistencies between verbal and nonverbal messaging, perception of that messaging by the recipient will be 55% from nonverbal cues, 38% from the tone of voice, and only 7% from the actual words spoken.[10] Actors are experts in nonverbal communication and clearly demonstrate that the same words delivered with different facial expressions or intonations can convey different meanings. For example, a clinician saying that they are very interested in a patient’s problem, while looking at their watch, is conveying two very different messages.
In one study medical residents who were more skilled at decoding nonverbal cues or were more effective in the use of nonverbal communication had more satisfied patients.[11] Another study found physicians who were good at reading and correctly interpreting other people's nonverbal cues had more satisfied patients who were more likely to return for their next appointment than physicians who were less able to interpret nonverbal communication.[12]
An interesting study of 57 general and orthopedic surgeons reported that when talking to patients, the surgeons whose voice tones reflected dominance and expressed less concern or anxiety in their voices were found to have significantly more malpractice cases filed against them than those surgeons that did not have those vocal behaviors.[13]
In another study of nonverbal communication, greater patient satisfaction was found to be correlated to greater physician nonverbal interest, less time reading the patient's chart, more physician immediacy (such as a forward lean), more nods and gestures by physicians, and closer interpersonal distance with the physician. Physicians who directly faced their patients, engaged in a moderate level of eye contact, and maintained an arm posture indicative of a readiness to act were rated as more empathic, interested, and warm.[14]
Communication and Health Outcomes
A review of 21 studies that looked at the effect of communication behaviors on patient health outcomes found that 76% of the studies reported that effective communication had a beneficial effect on measured outcomes such as emotional health, pain control, glucose levels in diabetics and management of hypertension.[15]
In another study, one group of patients were given training on how to increase their participation in care, by teaching them techniques for improving question asking, negotiating skills, and reducing feelings of intimidation. Compared to a control group, the intervention group had significant improvement in diabetes control and the authors stated (without presenting the data) that there were similar favorable changes in control of hypertension in the intervention group.[16]
Ways to Improve Communication
A study reported that only 49% of patients could recall decisions and recommendations made at ambulatory care visits, 36% could recall the information only if prompts were given and 15% could not recall the information at all.[17]
The teach-back technique is a method of assessing the patient’s understanding of what the clinician has tried to communicate by having the patient explain in their own words what the clinician has just told them. A systematic review of teach-back studies reported that 95% of the studies found it to be effective. Other studies found health literacy was increased, as was comprehension of post-visit care.[18] Additional studies have found that the teach-back technique resulted in less rehospitalizations,[19] In one study participants indicated teach-back helped them to remember what they had learned from their providers and had improved patient-physician communication, although some participants felt the process was a waste of time or unnecessary.[20]
The reverse process of clinicians repeating back to patients what they have told them gives the patient an opportunity to add information that might have been forgotten or to correct a previous statement.
Medical discussions and discharge instructions should be as simple and clear as possible without lapsing into medical jargon. In a study of patients’ understanding of common medical phrases, phrases that had less physician jargon in them were better understood. As examples, only 79% of the subjects knew that the phrase “your tumor is progressing” was bad news, only 67% knew that “positive lymph nodes” meant the cancer had spread and only 9% knew what “febrile” meant.[21]
The E4 Communication Model
One model for communication in the literature is the E4 model where the steps are:
Engage the patient
Empathize with the patient
Educate the patient
Enlist the patient
(1) Engage the patient
Introduce yourself (commonly forgotten). Let the patient talk and complete their opening statement.
(2) Empathize with the patient
Make the patient the center of your universe when talking to them and indicate your awareness of their needs and concerns. Use good verbal and nonverbal communication skills.
(3) Educate the patient
Some patients may not ask many or any questions, and physicians tend to give more information to patients that ask questions. All patients wish to have some basic information about their condition and the information listed below should be given to all patients whether they ask for it or not.[22,23]
What has happened to me?
Why has it happened to me?
What is going to happen to me, in the short-term, and later on?
What are you doing to me with respect to examination and tests?
Why are you doing this rather than something else?
Will it hurt me or harm me, for how long, and how much?
When and how will you know what these tests mean and when and how will I know what these tests mean?[22]
(4) Enlist the patient
Involve the patient with their care. Discuss problems or adverse events. If a common adverse complication can occur, warn the patient. Negative perceptions and litigiousness decrease with bad result if the patient is informed.[5] If a negative result occurs and you warned the patient about it you may be perceived as an astute clinician, whereas if not warned, the patient may view that as a sign of incompetence
Consider using partnership building remarks such as “Do you have any other concerns?”, “How do you feel about….?” In one study, only 2% of physicians’ remarks were partnership building.[23]
Conclusions
Poor communication, both physician-to-physician and physician-to-patient may be problematic. It has been definitively shown to increase malpractice risk, whereas good communication behaviors have been shown to reduce malpractice risk, improve patients’ understanding of their disease process, follow-up care, and improve health outcomes.
Simple techniques such as good eye contact, showing that one cares about the patient, allowing them to finish their opening statement without interrupting, all can lead to better patient rapport as well as decreasing malpractice risk if there is a bad therapeutic outcome. Clinicians should be aware of their own nonverbal behaviors as well as observing their patients for their nonverbal cues, both of which can improve physician-patient communication. Avoid using medical jargon and use terms a layperson would understand.
If the patient is amenable, having them use the teach-back method before discharge can help ensure understanding of your communications. In a similar process, it may sometimes be helpful for the clinician to repeat back to the patient what they have told him/her to give the patient a chance to add information that might have been forgotten or correct a previous statement.
Using a formalized method of handing off patients at the end of a shift or when changing from one service to another may assist communication and help reduce errors and malpractice risk. This author remembers being told by a senior resident during internship that the most dangerous time in medicine was change of shift.
We live in a time when clinicians’ speed of seeing patients is a measured metric and they are frequently typing on a computer keyboard while interviewing patients. These processes may lead to patient alienation. Patient satisfaction is not specifically related to the time spent with the patient but to the quality of the interaction.[24] Using good communication behaviors and ensuring the time spent with a patient is viewed as positive and therapeutic, may benefit both the patient and the clinician.
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References
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