After 25 years as an internist near Buffalo, N.Y., Edward Stehlik, MD, thought he was pretty good at connecting with his patients and helping them manage their health. But like many physicians, he also sometimes found himself distracted by other demands, such as an insurance form he hadn't finished completing or a colleague's e-mail that needed answering.
“There's no question, especially after you've been in practice for a while, that there are times when you're not as engaged with patients as you should be,” says Stehlik, governor of the Upstate New York branch of the American College of Physicians.
So he enrolled in a mindfulness meditation training study being conducted by Michael S. Krasner, MD, and others at the University of Rochester Medical Center. Seventy primary-care physicians attended a yearlong continuing-education course that included an initial eight weekly sessions and a daylong retreat, followed by monthly sessions where they learned techniques aimed at using attention and awareness skills to enhance communication with patients. “Patients know when the provider they're talking to isn't completely present,” says Krasner, whose research is published in the Journal of the American Medical Association (Vol. 302, No. 12).
During the study, Krasner taught the physicians simple techniques, such as stopping to take a breath as they enter the exam room and paying attention to the feeling of the doorknob on their hand as they turned it. “All of these things help you bring your attention back to the present moment,” he says.
The study results showed that training physicians to be mindful alleviates their stress and improves their well-being — effects that, in turn, enhance patient care. The physicians are better able to relate to patients and focus on their mental health. That, research shows, improves patient trust, leads to more appropriate prescribing, reduces health-care disparities and even lowers health-care costs, the researchers say.
Krasner's work is one of several studies exploring the role psychological factors play in patient communication and care, and examining the way physicians can improve care by learning to be better listeners and patient coaches. Psychologists are also advocating for medical schools to add compassion to their coursework as a way to help doctors-in-training understand how empathy can improve treatment outcomes.
“If you asked my patients, I think they would say I listen more carefully since the training and that they feel they can explain things to me more forthrightly and more easily,” Stehlik says.
Improving health outcomes
Psychologists, with their strong background in communication and relationship dynamics, are uniquely suited to lead research and interventions aimed at improving physician-patient interactions, says Kelly Haskard Zolnierek, PhD, a psychology professor at Texas State University.
“We also understand that multiple factors influence patient health,” she says.
With co-author Robin DiMatteo, PhD, a psychology professor at the University of California, Riverside, Haskard Zolnierek completed a meta-analysis in 2008 of 127 studies on physician communication and patient adherence to treatment, published in the August 2009 Medical Care (Vol. 47, No. 8). They found that patients of physicians who communicate well — by expressing empathy and concern, providing information on the illness and its treatment and encouraging patient participation in decision-making, for example — are 19 percent more likely to follow their physicians' recommendations on medication, diet, exercise and screening than those patients whose physicians communicated poorly.
The researchers also found that training physicians in how to improve their communication skills boosts patient adherence to those recommendations by 12 percent.
“While we can't make someone feel empathy deep down inside if they really don't feel it, there are a lot of behaviors that can be done by [physicians] to show empathy, such as asking open-ended questions, which give the patient a chance to talk about their challenges with a regimen,” Haskard Zolnierek says.
Physicians also need to pay attention to their nonverbal behaviors, says Judith Hall, PhD, a Northeastern University social psychology professor. When a physician checks his watch too often or speaks while looking at a computer screen instead of the patient, for example, patient satisfaction might decline. Hall and Johns Hopkins University's Debra Roter, DrPH, have analyzed thousands of videotapes and live interactions between physicians and patients. They've parsed phrases, postures and gestures to determine the key behaviors related to patient engagement, most recently looking at nonverbal sensitivity, or a physician's ability to detect a patient's fear, depression, bewilderment or other negative emotions.
A November 2009 Journal of General Internal Medicine (Vol. 24, No. 11) study led by Hall documents how a physician's understanding of nonverbal cues improves care and satisfaction. In the study of 275 third-year Indiana University School of Medicine medical students, students completed two nonverbal sensitivity tests developed by social psychologists. Researchers then analyzed videotapes of interviews the students had with a “standard patient” (actually a hired actor). In addition, 244 role-playing patients watched the videos and rated the medical students' performance, imagining themselves as the patients.
The results showed that students with higher levels of nonverbal sensitivity were better-liked and received higher ratings on their compassion than those who were less sensitive to nonverbal patient cues. The researchers also found that nonverbal sensitivity was higher among female students than male students, and it was also associated with less distressed and more engaged behaviors by the patient, one of the strongest indicators that a patient is taking an active role in his or her health and wellness.
Research by Roter and Hall also examines the role of physician gender in patient care. In a 2002 meta-analysis in the Journal of the American Medical Association (Vol. 288, No. 6), they analyzed 23 studies conducted between 1967 and 2001 that studied the effects of physician gender on patient communication. They found that medical visits with female physicians were, on average, 10 percent longer than those with male physicians. Female physicians also engaged in significantly more patient-centered communication, such as asking more about how patients were feeling emotionally. In addition, the patients of women physicians spoke more, disclosed more medical and psychosocial information, and made more positive statements.
“If a physician doesn't know that the patient isn't taking their pills, they might die,” Hall says. “Communication is intimately connected to health.”
Revamping physician training
In an attempt to bring a deeper focus on listening and other communication skills into medical training, three years ago Krasner helped develop and implement a curriculum at the University of Rochester called Mindful Practice. It is now a requirement at the medical school.
In May, he plans to offer a three-day retreat to train faculty in how to incorporate mindful practice curricula into their undergraduate, graduate and continuing-education programs.
At the University of Arizona, efforts by psychologist Daniel Shapiro, PhD, have helped medical students become more attuned to patient needs in another innovative way. Starting in 2006, Shapiro asked eight of his students to spend eight months accompanying patients with chronic conditions to work, physician visits and social events, and videotaping the experience. They also interviewed family and friends about how they've been affected by their loved ones' disorders, which included juvenile diabetes, cancer and Parkinson's disease.
“They were advised to throw themselves into their patients' lives,” Shapiro says.
The students then edited their hours of footage into 10-minute videos, which have been shown at medical schools across the country and at campus events. A summary and discussion of the project was also published in the September 2009 Academic Medicine (Vol. 84, No. 9).
Through developing these videos, the students built a greater connection to how an illness influences patients' entire lives, as well as those around them, says Nancy Koff, PhD, senior associate dean for medical student education at the University of Arizona College of Medicine.
Now chair of the department of humanities at Penn State College of Medicine, Shapiro has continued this work and now over 60 students have participated in the project.
“Until our medical training systems realign to focus more energy on prevention and care of the patient with chronic illness, it behooves us to invite patients to teach our students,” Shapiro says.
Amy Novotney is a writer in Chicago.