Maintaining a good bedside manner in a world of 15-minute appointments
Michael Howard Clary, DO, makes sure to shake every patient’s hand and make eye contact at the start of every appointment. He sits down, instead of standing, with patients at the beginning and end of each visit, and he engages them in small talk. His deliberate, carefully considered manner with his patients helps him better treat them, he says.
“A good bedside manner makes patients more comfortable with you, and they’ll tell you more,” says Dr. Clary, a family physician in Roanoke, Va., who was recognized for his bedside manner by Our Health Magazine every year from 2010 to 2013. “If patients are not comfortable with you, they will not tell you everything that’s going on because they fear you may judge them.”
However, Dr. Clary’s efforts to communicate well with patients all involve time, which is, for many physicians, an ever-shrinking commodity.
Reduced reimbursement, among other modern practice constraints, have many physicians seeing patients in 15-minute increments, sometimes at best.
Such time limits are hard on bedside manner, says Justin Faden, DO, a psychiatrist who has written about physician empathy for The Journal of the American Osteopathic Association.
“Good communication is a critical core competency for physicians and other providers to have. It’s not something you can leave at the desk when you’re walking to the patient’s room.”
“At times, you’re going miss out on getting the background of the situation, especially if it’s mental-health-related,” says Dr. Faden, an assistant professor of psychiatry at the Rowan University School of Osteopathic Medicine in Stratford, N.J. “The patient is going to feel rushed and flustered. Inadvertently, patients are going to get the impression that the doctor doesn’t care, which isn’t fair. But the doctor has an extremely limited amount of time to devote to each patient.”
Still, physicians can employ tactics to communicate effectively with patients amid time restrictions—some of which may help them get more accomplished, says Edward Leigh, who directs the Center for Healthcare Communication in Cleveland and coaches physicians on bedside manner.
“I’ve had a number of physicians tell me that connecting with people emotionally actually shortened their visits because they were able to establish rapport very quickly,” he says.
Connecting emotionally may also lead to better care. Studies suggest that physician empathy impacts patient outcomes. Diabetic patients with more empathetic physicians were significantly more likely to have their illness under control, according to a 2011 Academic Medicine study. A 2012 Italian study found a lower rate of metabolic complications among diabetic patients whose physicians were more empathetic.
Bedside manner and the bottom line
Although physicians have less time, their communication skills have become more important to their paychecks in the last few decades, Leigh says. Insurance carriers and employers are increasingly tying physician reimbursement to patient satisfaction scores. Also, disgruntled patients today are just a few clicks away from broadcasting their discontent.
“If a physician didn’t have good bedside manner 20 years ago, there were no financial issues related to it. There was no Facebook to worry about, there were no physician rating sites to worry about,” he says. “But now it’s a different world. Basically, physicians have no choice but to improve.”
Communicating well with patients—in particular, being transparent and direct with them—can also help stave off lawsuits, Dr. Clary says.
“If you’re honest with patients and something goes wrong and you tell them right away, they will understand,” he says. “Not everything you do with every patient works out the way you want it to. Every physician has gone through that. If you’re just honest with patients, then they are less apt to blame you.”
Indeed, patients who sue for malpractice are often unhappy with their physicians’ communication style, according to a 2003 Baylor University Medical Center Proceedings paper that examined several studies.
“Overwhelmingly, the dominant theme in these studies’ findings was a breakdown in the patient-physician relationship, most often manifested as unsatisfactory patient-physician communication,” the authors wrote. “Study participants described the perceived communication problems as follows: physicians would not listen, would not talk openly [and] attempted to mislead them.”
Some physicians think having a good bedside manner is optional, says Kevin M. Klauer, DO, the chief medical officer of Emergency Medicine Physicians in Canton, Ohio. But from a risk-management standpoint, it’s a necessity, he says.
“Good communication is a critical core competency for physicians and other providers to have,” says Dr. Klauer, whose company provides training on bedside manner to its physicians. “It’s not something you can leave at the desk when you’re walking to the patient’s room. It’s just like your stethoscope. It’s probably more important than your stethoscope.”
Even though, as an emergency physician, Dr. Klauer is often rushed, he takes time to empathize with patients. He often opens visits by apologizing for the patient’s wait in the emergency room. This would work well in physician’s offices too, he notes, where patients may wonder why they waited 40 minutes for an appointment they made six months ago.
“I’ve gotten in the habit that no matter how long patients have waited, I apologize for their wait,” he says. “If it’s been two minutes, they are going to think, ‘What a well-run emergency department.’ If it’s been three hours, then they were expecting an apology and they get it.”
Next, Dr. Klauer says he lets patients speak uninterrupted.
“Physicians sometimes seem rushed. We cut people off and we don’t let them finish their statements,” he says. “That is a dead giveaway that you’re not interested in what they’re saying and you’re trying to conclude things quickly and get out of the room. My recommendation is to let the patient speak for one minute without interruption, no matter what he or she is talking about. If it’s not valuable to you in your assessment of the patient, sit there and listen and after a minute you can redirect the patient to the information that you need. But patients have waited. They should be given the opportunity to express themselves.”
Internal medicine physicians interrupted their patients’ opening statements 37% of the time, a 2005 Journal of General Internal Medicine study found. The interrupting physicians let their patients speak an average of 16.5 seconds before cutting them off.
When patients have a chance to share their whole story, Leigh says, appointments can become shorter because physicians learn relevant details as the patient’s story unfolds.
“A number of physicians told me, ‘Before, I was just throwing all these questions out at patients. I think I was confusing them, and I was missing things,’ ” he says.
“I’ve had a number of physicians tell me that connecting with people emotionally actually shortened their visits because they were able to establish rapport very quickly.”
Leigh also notes the benefit of taking time to establish an emotional connection at the beginning of the appointment. As an example, he notes that many TV commercials feature a light exchange between two or three people before the finer details of the product are mentioned.
“Advertisers first connect us emotionally to draw us in, and then we get the information after that,” Leigh says. “But if we went right to the information about the policy, we probably would not be very interested. It’s a perfect example of how we’re drawn in through an emotional connection, and then we’re ready to listen to the information. But in health care we just go right to the information.”
Dr. Clary says he often asks about patients’ families and where patients live and work.
“Sometimes patients will start opening up to you,” he says. “If you’re going through their social history, you also can ask questions.”
For instance, when patients mention their jobs, physicians can ask how long they’ve been there, where the office is and what they do.
For physicians who don’t know where they’ll find the time to chat up patients about their siblings and neighborhoods, Leigh stresses that small talk can establish a connection in less than a minute.
After the main course of a patient visit—the evaluation—Dr. Klauer likes to hand out his business card to the patient.
“I don’t care if you’re 3 years old or you’re 83 years old. If you’re in the room, you’re getting a card,” he says. ” ‘Here’s a card. If you need anything, just let me know and we’ll take care of it, because we want you to be comfortable while you’re here.’ Patients are not qualified most of the time to judge the medical care that we provide, but they are more than qualified to judge whether you care or you tried hard to be nice to them.”
Dr. Clary, who sits down to talk to patients at the beginning of a visit, tries to be seated again at the end of appointments while he explains treatment to the patient. He also tries to plan his day so he can give extra time to patients who need it.
“If you have a patient with multiple medical problems such as diabetes, hypertension and congestive heart failure, it’s hard to evaluate him or her in 15 minutes and figure out what’s going on,” he says. “You probably should book these patients a little longer—maybe up to 30 minutes. You do get reimbursed if you spend the time with the patient and it’s documented. And if you have a patient who you think is going to take a really long time, you can book him or her for the last appointment of the day.”
When patients unexpectedly have a list of problems longer than their appointment’s time window, Leigh suggests using delicate language to explain time constraints.
“The worst thing to say is ‘We don’t have time to talk about that,’ ” he says. “What I recommend is saying to the patient, ‘I wish we had time to talk about everything today. How about if we focus on these two things today? And then we’ll make an appointment to talk about the other two things. How does that sound to you?’ That works very well.”
To foster improvements in patient satisfaction across an institution, Leigh suggests providing physicians with a tip every week during a meeting.
“It could be something as simple as making sure you always get the patient’s name right,” he says. “I worked with one practice, and when we were looking at the list of patients they were seeing that day, they would have the name the person goes by in parentheses. ‘Robert Smith, goes by Bob.’ So one week it could be learning the patient’s name. The second week could be making sure you always greet the family members and make sure they have a good experience. The third week, make sure you always ask ‘What else?’ to get all the issues up front. Every week, just build it into the culture.”
Physicians at Dr. Klauer’s company can participate in an intensive two-day training program on bedside manner, he says, where they have the opportunity to perform simulated examinations with patients and see videos of themselves in action.
“Patient satisfaction is a core competency, and we’ve really built some resources around helping physicians get better at it,” he says. “We’re not just telling them to get better at it. We’re giving them some resources so they know how to get better at it.”