As a family physician, you already have excellent communication skills. How else could you have created such close ties with your patients? But, like other doctors practicing today, you probably have more time constraints on your schedule than ever before. In a health care environment where the average patient visit lasts only 15 minutes, something's got to give, right? If you're not careful, that “something” may be the open lines of communication you've established with your patients.

George T. Wolff, MD, a family physician who has practiced in Greensboro, N.C., for more than 40 years and now teaches family medicine part time, has watched it happen. “Because HMOs and hospitals are demanding that you see a certain number of patients per day, many doctors have to cut down on time they can spend with their patients,” he says. “And the first thing that usually suffers is communication.”

But it doesn't have to be that way. It is possible to see more patients in less time and still be an effective communicator — you simply need to communicate “smarter” by making better use of the time you've got. To communicate smarter with your patients, you'll need to refine the basic communication skills you already have, make the necessary adjustments in your communication style to accommodate today's more participatory style of care, and take steps to go the extra mile.

Refining the basics

If you're like most family physicians, you've probably already mastered the basic communication skills that keep your patients coming back: You listen empathetically. You have a keen understanding of nonverbal behaviors. You always try to give well-reasoned explanations. But because time is in increasingly short supply, you may feel you need to reduce your talk time. Be forewarned: Taking shortcuts too often or in the wrong places may weaken the doctor-patient relationship you've worked so hard to build, and it also may keep you from obtaining crucial information necessary to your patients' care. To maintain the quality of your communication in today's fast times, make sure you're doing all those things you already know you're supposed to be doing:

Don't omit the pleasantries. Along with other benefits, it's widely known that patients are more likely to follow advice if they have a good relationship with their doctor. So anything you can do to build rapport isn't just a nicety — it's an essential part of patient care.

“One thing that's very important is how you enter a room,” Wolff says. Even with time at a premium, walk into the exam room with a smile, shake the patient's hand, call the patient by name (first name or surname, whichever the patient prefers), and sit down. “Sitting down places the doctor at eye level or below eye level,” Wolff says. “This relaxes the patient so that he or she will communicate more openly.”

Don't appear rushed, even if you are. “Patients are greatly irritated when their doctors appear hurried,” says Ken Davis, MD, a family physician in Conroe, Texas, who has worked in a multispecialty group practice for 20 years. To keep his patients from feeling that they're being rushed, Davis refrains from two specific non-verbal behaviors: looking at his watch and keeping one hand on the doorknob. “These behaviors imply that the patient in the room isn't as important as the one who's coming in next,” Davis says. “It's important to make each patient feel that they are in the center of the universe.” Once you're in the exam room, make sure you're really there: Focus your attention on the patient and stop yourself from being preoccupied with what's happening on the other side of the exam-room door.

Keep conversations on track. Carolyn Thiedke, MD, a family physician in Charleston, S.C., and a member of the FPM Board of Editors, believes helping patients stay on track is key to increasing efficiency and maximizing the value of the time you have with them. “While most patients present their concerns in a straightforward way, others tend to go off on tangents,” says Thiedke. While you can get useful information from these departures, Thiedke suggests using your intuition to determine when the conversation begins to lack relevance. “If they're talking about their brother-in-law's surgery or a conversation they had with their neighbor,” she says, “you should gently guide them back to the matter at hand.”

Communicate with a dual purpose. Davis believes that doctors can learn a lot from their patients, even during informal conversation. “When you ask a patient about her kids, you can also ask if they are caught up on immunizations,” he says. “This type of interaction not only demonstrates your interest in the patient, it also gives you information that should be noted in the chart.”

Listen without interrupting. While your tendency may be to ask your patients a lot of questions up front, Wolff says you'll get more information and save time in the long run by actively listening to the patient without interrupting. “Studies have shown that the patient normally speaks for an average of 18 seconds before the doctor interrupts,” Wolff says. “But if the doctor lets them speak for three to four minutes, they tell you 90 percent of what's wrong with them.”

It's also a good idea to check your listen:talk ratio. In one study,¹ doctors estimated that they listened more than they talked during office visits. But their estimates were incorrect: The study showed that, while patients talked 54 percent of the time during the history taking, physicians tended to dominate the conversation during all other parts of the visit.

Relate with your eyes. Avoid spending the patient visit focusing on a computer screen, writing down information or reading a chart. Really look into the patient's eyes. Your eye contact should be direct but intermittent (not staring), and it should be sincere and convey interest. “When you make what I call an ‘eye connection,’ patients often perceive they have spent more time with you than they have,” Davis says.

Organize your interviews. Most family physicians excel at interviewing — asking open-ended questions, seeking clarification, using reflective phrases and avoiding statements that might evoke defensive responses. In an effort to be comprehensive, however, some interviews may go on too long. To make the most of your interview time, Thiedke recommends structuring your patient interview. For example, if you suspect there may be a psychological component to a patient's complaint you may want to try the “BATHE technique.” It's designed to fit smoothly into a 15-minute patient visit.² The BATHE technique divides the patient interview into the following components:

• Background (“Tell me what has been happening.”);

• Affect (“How do you feel about that?”);

• Trouble (“What's upsetting you most about it?”);

• Handling (“How are you handling the situation?”);

• Empathy (“That must have been difficult.”).

Making necessary adjustments

Being an excellent clinician and a master of basic communication skills may no longer be enough to ensure patient retention in your practice — especially considering how patients' expectations have changed. As Davis points out, today's patients want to be partners in health care decision making; they no longer want to be told what to do. They want reasoning and proof to replace a patient-physician relationship that was traditionally built on blind trust. Given these changing dynamics, what adjustments should you make in your professional style? Some that you may want to consider include the following:

Make an extra effort to build trust

“Many patients today are seeing physicians they don't know and haven't heard much about,” says Wolff. For example, one of Wolff's patients, an elderly woman who had been seeing a cardiologist each month, was instructed by her HMO to see a family physician instead. “It took three months of getting to know her before she felt comfortable seeing me,” Wolff said. He believes that it's important to establish at least this level of comfort with all patients — including the ones who “choose” you because of your managed care affiliations. Why? Because patients disclose more information to physicians they trust. “If you see a patient over a period of years, you can cut to the heart of the matter a lot quicker,” Wolff says. “You know their family environment and job situation. In the long run, it helps to shorten up each office visit.”

And if you have only a period of months in which to get to know a patient, it's that much more important to use every visit to build trust. Establishing a history of reliability is one way to build trust. For example, if you tell the patient you're going to call with lab results, make certain that you do just that. Doing this the first time will show your patients that they can count on you. Doing it again and again will build trust.

Be aware of changing dynamics. Take some time to analyze your own interactions with patients. It's your practice style more than your skill as a clinician that's the litmus test most patients use to evaluate you. In a study contrasting different styles of patient care,³ researchers found that physicians who used a participatory model of care (i.e., the doctor serves as educator, shares decision making and encourages patients to participate in their care) had twice the patient retention rate as physicians using the traditional authoritative style of care (i.e., the physician is the patriarchal figure and decision maker).

Patients who were able to ask questions and offer opinions about the treatment process were found to have measurably better outcomes. To move toward this participatory style of care, physicians need to encourage adult interactions, keep conversation at the patient's level of understanding and let the patient do most of the talking. Patients who take a partnership role in their care will often share more information with you during the office visit and may be more motivated to comply with your treatment plan.

Empower your patients. Even though many patients prefer a more participatory role in their health care, you'll continue to encounter some patients who may find you intimidating. “A lot of patients perceive an imbalance in the relationship and think that all the power is in the doctor's favor,” Davis says.

He believes that these patients will feel a greater sense of participation in their care if the options available to them are explained by the doctor or a staff member. For example, some patients who call for a same-day appointment and hear that the schedule is full may think they have no other choice but to make an appointment for another day. “Patients need to know that they can ask additional questions,” says Davis. “For example: Is there anyone else who can see me? Should I go to the emergency room? Could you call me if there's a cancellation or a no-show? Can the doctor work me in?”

Manage patient expectations. Media coverage about medical advances and new technologies has helped to create an unrealistic expectation that doctors can diagnose and cure just about anything. Wolff emphasizes the importance of explaining to patients what is realistic. Thiedke thinks it's also important to manage patients' expectations about the use of the physician's time. “In the past, I may have created expectations that we have all the time in the world,” she says. “But that's not realistic anymore.” To address this, she says, office staff who schedule appointments should be coached to block out more time for patients with a long list of concerns.

Provide more information in less time. Even though people today are inundated with information about their health, they still “want more information [from physicians] and are less willing to accept our word as gospel,” Davis says. To address this thirst for knowledge, consider whether you're pouring enough information into the patient visit — it may be less than you think. Some studies have found significant discrepancies between the amount of time physicians say they spend giving information (e.g., explaining an illness or coaching about lifestyle changes) and the amount of time they actually spend.⁴ Of course, the more information you provide, the more important it is to test the patient's understanding of that information (For example, say, “Now let's run through this again: How are you going to get the right dose of insulin into the syringe?” instead of “Do you understand my instructions?”)

One way to provide more information to your patients without a larger time commitment is to integrate patient education materials into the office visit. “We keep a file of the patient education handouts that appear in American Family Physician each month,” Wolff says. “So, if I have a patient with hypertension, I ask the nurse to give the patient that handout. While the patient is reading it, I see another patient, and then come back in and answer the patient's questions. In some cases, if I need to save time, I ask the nurse to go back in to explain it.”

Davis has found that he can provide more information more efficiently by delegating some patient education tasks to his nurses and other qualified staff members. He relies on his nurses to provide patient education on medications, drug interactions, diabetes management and other subjects. Patients in his practice can also help themselves to a patient education library, stocked with brochures, books and videotapes, that's conveniently housed in an extra exam room.

Going the extra mile

Even after you've refined and adjusted your style of practice, there's still more you can do to meet — and exceed — your patients' expectations. To make your patients even better informed while enhancing the doctor-patient relationship, consider doing the following:

Shore up your office systems. A work-place that's been arranged specifically for your convenience and efficiency will enable you to give more time to your patients. When Thiedke and her colleagues did a walk-through of their practice to evaluate processes such as scheduling and the way patients moved through the office, they identified several areas that were lacking and then worked toward improving them. As you do a walk-through, it's a good idea to look at your office from the patient's perspective as well as from your own. To find ways to improve his practice's efficency, Wolff relies on several sources: He talks to patients, conducts patient satisfaction surveys, and asks for honest feedback from friends who have called or visited his practice.

Give all new patients a welcome letter. Thiedke thought so favorably of a letter that Paul Frame, MD, had sent to his new patients that now she gives patients a version of that letter herself (see “A sample welcome letter”). The letter you hand out should provide insight into the kind of care your patient can expect to receive, help ease the transition to a different practice, and help the patient feel familiar with you and your practice at the first office visit.

Use computers creatively. Some physicians are now using e-mail to answer patients' questions and avoid getting tied up in lengthy telephone conversations. “I know one doctor who even has e-mail hours,” says Davis. “It's like a chat room. It keeps patients in touch with their doctors, and with managed care anything you can do to decrease the demand on a doctor's time helps.” Thiedke uses her computer as a patient information tool; she'll occasionally tell patients about sites she's located on the World Wide Web that are specific to their health care needs. (For more information on using e-mail and the web to enhance patient communication, see “Getting Patients Off Hold and Online,” January 1999.)

Make special efforts to meet individual needs. Thiedke keeps her patients in mind when she's conducting research or going through materials from suppliers. “In one case, a mother had brought in her child with what I thought were growing pains. While I was at a medical library soon after the visit, I saw a paragraph on growing pains that I photocopied and mailed to the mother.” Thiedke also saves catalogs of medical products and devices and passes them along to patients who might find them useful; in the past she's given patients catalogues offering orthotic devices for shoes, massagers and books specific to their needs.

Educate your staff. Communication isn't just a doctor-patient issue. Your nurses and office staff also represent you to your patients and can quickly short-circuit open lines of communication if their people skills are weak. To strengthen the staff-patient relationship, Wolff recommends periodic staff training sessions on patient communication and related topics. It'll also be a time-saver for you. If you invest in teaching your staff effective communication skills, they'll pay you back by building patient trust and relaying pertinent patient information to you before you even step into the exam room.

Do the unexpected. Davis keeps in contact with his patients between visits by routinely calling two or three of them each day. “I don't call just the people who call me. I also call people just to see how they're doing, such as a new diabetic patient who may not expect to hear from me.” Not only does Davis make these calls, his nurse does too.

Follow up. Don't just leave it to the patient or the referral physician to get back to you about test results or other information. Start by developing some sort of trigger (anything from red flags on a calendar to a tickler card file to a computerized reminder system) to remind your nurse to call for information if you haven't received it as expected. This will help you stay in the loop and maintain continuity of care as well as showing the patient you are interested in his or her situation. Of course, it's important to be sure that the other party understands that keeping in touch is a two-way street and that you're expecting them to do their share.

Make your practice even more “family-specific.” Even today, some patients still don't know the difference between a family physician and other doctors. And, as Wolff points out, some still don't realize that family practice is a bona fide specialty. When one of Wolff 's patients asks to see a specialist, he stops for a “teachable moment.” “I tell them I am a specialist,” he says. “I am a diplomat of the American Board of Family Practice. If you need a specialist in a narrower area, we can find out what you need and arrange it. But in the meantime, let's treat the whole person.”

He also educates his patients by placing brochures about family practice in prominent places in his office, posting an AAFP seal on the front door, and ensuring that “family” is always a topic during patient visits. (For more tips, see “Remind Patients of Your Scope of Practice,” October 1998.)

To further emphasize “family,” Wolff places a skeletal genogram and a problem list in the front of each patient's chart to identify each of the patient's family members and their risk factors. Wolff says that by using these forms, he often sees something about the patient's family on the genogram to add to the problem list as a possible risk factor. He has also found that these forms encourage him to talk to patients about their families and serve as a reminder of other family members who may need to participate in a patient's treatment plan.

The benefits

The single most important criterion by which patients judge you as a physician is the way you interact with them.⁵ And, with shorter patient visits now a reality, you have even less time to “make or break” the patient-physician relationship. It is therefore vital that you develop your understanding of your own communication style and adjust that style to meet the needs of various patients. Many patients today want to be part of the treatment team. If you include your patients as fully informed partners in their care, they'll pay you back with increased satisfaction and better compliance and retention rates for your practice. In the process, it's likely you'll discover more satisfaction in your work, renewed motivation and increased productivity.