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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 variations in patients’ levels of comprehension, and cultural barriers. Advancing technology also pro- vides increasing amounts of information 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, physicians must understand the characteristics and benefits of good communication, improve their communication skills, and appreciate the consequences of failing to communicate effectively. Is There A Communication Problem? In 1998, the American Academy of Orthopaedic Surgeons commis- sioned a survey of consumers (patients) to “probe their perceptions and attitudes towards orthopaedic 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 interviews from a random sample of the public were conducted, followed by a second wave of 407 interviews, for a total consumer base of 807 interviews. 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, orthopaedists self-rated themselves as good listeners and as caring and compassionate (so-called high-touch attributes). 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 deterioration of effective physician-patient communication. The American Academy of Orthopaedic Surgeons has identified that patients rate the orthopaedic profession as high in technical and low in communication skills. Poor communication, especially patient-interviewing skills, has been identified in medical students 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 malpractice suits, and it likely contributes to reduced costs of care. Recognition of the importance of communication has influenced medical schools to revise curricula 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 communication, 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 listening, care, and compassion—high- touch attributes (Table 2). The com- parison of the orthopaedists’ perception of themselves and how patients perceive them reveals a significant gulf (Table 2). The study also indicates that orthopaedists, compared with primary care physicians, are rated as less caring and compassionate and as more technically 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 relations campaign be initiated that combined a high tech–high touch image of the orthopaedic profession. 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 listen to their patients. The AAOS also has initiated an education program in communication, starting with a section of the Bulletin devoted 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 communication “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 communication 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 subsequent interchanges serve three basic functions: gathering information, developing and maintaining a therapeutic relationship, and counseling the patient and negotiating plans for treatment. Gathering Information The primary goal of the medical interview is to gather as much useful 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 treatment 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, cultural values, and socioeconomic variables of patients and their family 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 resident 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 accomplished 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 relationship 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; recognizing emotions and responding empathically to those emotions; recognizing and responding appropri- ately to conflict; and remaining aware of one’s own personal needs, values, and biases while maintaining 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 complained of low back pain following heavy lifting 1 month earlier. Dur- ing the interview, the patient reported 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 recommended 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 doctor 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 increased back pain, there was no change in his affect or in the physical 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 orthopaedist 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 condition 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 relevant family members that will help them understand the patient’s condition, options for treatment, and likely outcome. The important components are providing effective education and counseling, motivating changes in behavior, and negotiating treatment plans. 7 Failure to understand 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 education 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 examination revealed 90° of flexion and 35° of abduction. She walked well with a cane, and radiographs showed a well-seated THA. However, the patient was depressed and unhappy with the results. More intensive physical therapy was advised; 6 weeks later, her flexion had improved to 100° and abduction to 45°, and the patient walked without a limp. Radiographs showed excellent prosthetic positioning. Again, however, she indicated dissatisfac- tion with the results and was depressed. 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 outcome as excellent. The Benefits of Good Communication Good physician-patient communication has been associated with improvements in patient and physician satisfaction, greater compliance with treatment plans, better and more appropriate medical decisions, and reduced malpractice claims. Good communication also likely contributes to improved cost effectiveness in providing care. Patient health is more apt to be improved with congruence between patients and physicians in identifying problems and determining course of treatment. 8,9 Stewart 1 reviewed MEDLINE citations from 1983 to 1993 using physician-patient relations as the primary medical subject heading. She concluded that there were positive benefits for good communication 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 audiotapes recorded during visits to primary care physicians. 12 Patients and physicians were given exit questionnaires about the problems they had discussed, the priority of each problem, satisfaction, and patient inten- tion to comply with the physician’s recommendations. Patient satisfaction correlated with the patient’s perception of the physician, where- as physician satisfaction correlated with the use of open-ended questions. These findings are consistent with those of other studies. For example, the satisfaction and compliance 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 requests in psychiatric and family practice clinics are associated with greater satisfaction. 15,16 Stringer et al 17 used 16,230 surveys of patient encounters to ana- lyze the office practice of orthopaedic surgeons. Notable correlations were found between overall patient satisfaction and the following variables: 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 communication: their most common complaint was that the orthopaedist talked down to them. Deyo and Diehl 18 found that patient satisfaction was greater in patients with low back pain when an adequate, comprehensible explanation was given for the cause of their symptoms. Compliance With Treatment Plans Transmitting appropriate information 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 physician discusses a recommended treatment with the patient and sometimes supplements the discussion 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 emotionally 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 physical examination revealed some loss of sensation in the L5 nerve root distribution bilaterally. Spinal radiographs established the presence of a grade II L5-S1 isthmic spondylolis- thesis. Computed tomography confirmed entrapment of the L5 nerve roots. The surgeon presented the nature of the problem in detail to the patient and discussed both surgical and nonsurgical treatment options. One week later, the orthopaedist 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 comprehension and noncompliance extend to the use of reading material. De- spite the widespread availability of patient-directed literature, few orthopaedists use it routinely. Patients have major variations in reading comprehension, and much material used in health education is beyond the understanding of many patients. 20-22 One analysis of medical illiteracy revealed that 40% of patients were unable to understand written instructions to take medications on an empty stomach. 20 These variations in medical literacy 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 respondents 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 status and poorer outcomes from medical 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 communication are fewer. Effective strategies include postdischarge telephone calls to monitor a patient’s recovery and ascertain the need for more information. 23 Problems in both verbal and written communication also can arise when a patient requires multidisci- plinary care. Unless there is a well- coordinated team of caregivers, conflicting 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 physical 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 information 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 language 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 presence of a torn medial meniscus. An uneventful arthroscopic partial men- iscectomy was performed. One month later, the patient still complained of pain and difficulty moving the leg. Aside from stiffness, the physical examination was unremarkable. At the third follow-up visit, the surgeon asked the companion why she thought the patient was taking so long to get better. The companion noted that the patient had not previously had any exposure 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 physician, however, because doing so would have been disrespectful. When asked what should be done, the companion suggested using traditional 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 physicians. 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 obtain 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 situations because of failures in communication. 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 conditions. 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 established 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 (booklet alone) group (32% versus 47%, respectively; P = 0.05 by Kaplan- Meier test). However, of the patients 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 informed. 29 Reduced Risk of Malpractice Suits There is a greater risk of medical malpractice suits with poor physician-patient communication or a breakdown in communication, particularly when complications of treatment have occurred. 30-32 Beck- man et al 30 studied patients’ deposi- tions to determine the causes of malpractice and found the following causes for lawsuits: deserting the patient (32%), devaluing the patient’s and/or family’s views (29%), delivering information poorly (26%), and failing to understand the patient’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 malpractice suits. 31 Primary care physicians 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 patients and reinforced. 34 Similarly, effective preoperative education has been associated with reduced length of hospital stay and fewer complications, 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 malpractice suits. To date, however, no study has explicitly quantified any cost benefits attributable to mutually satisfying physician-patient communication. Improving Communication The Status of Effective Communication Skills Despite the importance of communication 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 relationship 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 students entered medical school with good interpersonal skills and interests 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 completed all of their major clerkships met with a standardized patient and were asked to complete an interview 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 analyzed, poor or very poor interviewing competencies were identified in the majority of the interviewers. 36 The absence of effective communication 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 average 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 problems were elicited. To determine whether the medical 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 surgeons 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 minutes 31 seconds, but in 9% of the encounters, the physical examination was started before any history had been taken. Patient education and counseling accounted for almost half the phase (5 minutes 24 seconds) 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 patient’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 evaluated for right hip pain. Although the orthopaedist spent time dis- cussing the indications, complications, and likely results of THA, he was pressed for time, and his cur- sory assessment suggested that the patient had no other medical problems. An uneventful THA was performed. 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 postoperative 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 symptoms resolved. On closer questioning, 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 communication 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 communication skills. The report noted that many of these teaching methods were useful but that in the absence of explicit expectations and feedback 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 seeking 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 medicine 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 communication 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 personal 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 communication 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 communication skills. Lipkin et al 7 have developed a prototype that involves carefully supervised group discussions, encounters with actual patients, role playing, videotapes, con- tinuous feedback, and formal evaluation. 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 primary 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 definition and managing patients’ emotional distress. The trained group had markedly greater skills in problem 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 workshop setting. The major impetus that will change medical curricula, however, will come from the inclusion of communication 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 communication. 42 By linking licensure examinations 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 examinations. 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 orthopaedic 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 communication 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 communication, formal residency training in communication, and the opportunity for those in practice to refresh their communication skills. For the practicing 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, videotapes of simulated physician-patient encounters, and peer discussions, all elements of successful adult learning. 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 communication 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 communication serves three basic functions: gathering information, developing and maintaining a therapeutic relationship, and counseling the patient (including negotiating plans for treatment). Good communication results in several benefits, including patient and physician satisfaction, improved patient compliance, appropriate medical decision-making, increased likelihood of good outcome, and reduced risk of malpractice suits. Effective physician-patient communication also likely contributes to the cost-effectiveness of care delivery. To improve the status of medical communication, communication skills must be included in the curricula of medical schools, and practicing physicians should be encouraged to attend workshops that refresh and enhance mutually beneficial communication skills. Physician-Patient Communication Journal of the American Academy of Orthopaedic Surgeons 104 References 1. Stewart MA: Effective physician- patient communication and health outcomes: A review. CMAJ 1995;152: 1423-1433. 2. Levinson W, Chaumeton N: Communi- cation between surgeons and patients in routine office visits. Surgery 1999;125: 127-134. 3. American Academy of Orthopaedic Surgeons: 1999 Public Image Investiga- tion. Second report. Rosemont, IL: American Academy of Orthopaedic Surgeons, May 1999. 4. Rogers C: Communicate: Your body language speaks loudly. American Academy of Orthopaedic Surgeons/ American Association of Orthopaedic Surgeons Bulletin 2000;48(no 5):29-30. 5. 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