Good communication is key to good medicine (Proceedings)

Study after study in all walks of life demonstrate the importance of good communication. This is as true in scientific fields as in more obvious professions such as teaching or the law. Some of the studies documenting the need for good communications in veterinary medicine include:

     • PEW National Veterinary Education Program

     • AVMA Market Study (1999)—"Veterinarians are strong in scientific, technical and medical skills and lacking in communication and management skills necessary for success in practice."

     • Brakke Management and Behavior Study (2000)—Identified three business practices to increase practice income (employee longevity, employee satisfaction, and client satisfaction)

     • Personnel Decision Study (2003)—Identified non-technical competencies for career success (business acumen, work life balance, effective communication, and leadership skills)

     • AAHA Compliance Study (2004)—Lack of communication in making recommendations

     • AVMA-Pfizer Business Practices Study (2005) —Identified client relationships as a pillar of financial success

Strong scientific evidence in the human medical field demonstrates the relationship between communication and more positive medical outcomes. A recent study by Jody Hoffer Gittel and colleagues looked at the outcomes of joint replacement surgery in nine urban hospitals. Some of the hospitals invested heavily in hiring and training for relational competence (an ability to interact with others to accomplish goals; others focused on hiring the most technically qualified individuals with less emphasis on relational competence. The hospitals that considered relational competence important showed significantly improved patient outcomes:

     • 31% reduction in length of stay

     • 22% increase in quality of service patients perceived

     • 7% increase in postoperative freedom from pain

     • 5% increase in postoperative mobility

A very recent study by Morris and Latham in the veterinary field demonstrated:

     • Significant improvement in veterinary students' communication skills with increasing levels of training

     • No significant difference between no training and intermediate training

     • Client's recall highest in student group with highest level of communication training

A number of myths abound regarding communication skills. The first is that communication is a personality trait and you either have it or you don't. In reality communication is a series of learned skills and anyone who wants to can learn them. Another myth is that experience is a good teacher of communication skills. In reality, experience alone tends to be a poor teacher of communication skills—experience just tends to reinforce habits whether those are good or bad habits!

One of the next myths is that focusing on communication takes too long to be practical. This is obviously of great concern to any busy professional. In reality, relationship centered communication takes no longer than traditional approaches and is more efficient in the long run and results in greater client satisfaction and better medical outcomes.

One study demonstrated that the average consultation for doctors who don't use patient centered skills takes about 7.8 minutes. The average for doctors who have mastered patient centered skills is 8.5 minutes. It's a little longer for those in the learning stages—about 10.9 min for doctors who are learning relationship centered skills. But once mastered, it's clearly no more time-consuming.

The four key elements of good communication are:

     • Non-verbal communication

     • Open ended inquiry

     • Reflective listening

     • Empathy

Non-verbal communication is about building the relationship and fleshing out the verbal communication. Nonverbal communication includes all the behavioral signals that go on between interacting individuals, exclusive of verbal content. Roughly 80% of all communication is nonverbal; these non-verbal signals are generally involuntary. 20% of communication is verbal and intentional. Voluntary verbal communication reflects a person's thinking. Involuntary nonverbal communication more accurately reflects a person's feelings. When mixed messages are sent, the nonverbal message more truly reflects the person's actual feelings and will predict his behavior.

Open-ended questions encourage the person to elaborate or to tell a story without shaping or focusing the content. The goal is to obtain a story not an answer and to find the meaning of the communication, not the facts. Simple examples include questions that start with "Tell me...." Or "Describe for me...." "What" and "How" questions are also effective. "Why" questions are less effective; they tend to provoke defensiveness. Open-ended questions are part of a funnel approach to gathering information—start with the broad questions and end with the more specific ones as the important parts of the story emerge.

In the beginning, ask broad, open-ended questions such as "How does Fluffy behave in the morning when you see him acting strangely?" As you get the story, focus on on specifics with closed-ended questions to clarify details—"Which leg to you think he is favouring?"

Doctors tend to think this technique will be overly time-consuming but perceptions of time can be very inaccurate. Doctors interrupt patients within 12-23 seconds but patient stories, if fully listened to, are usually less than 60 seconds.

Reflective listening is a technique that involves reflecting back, in your own words, the content or feelings behind the person's message. This helps you, the receiver, get a better understanding of the information transmitted to you and helps the sender feel that he/she has been heard and understood. There are three basic kinds of reflective listening:

     • Simple repeat of clients words—"So Fluffy threw up twice last night."

     • Summary and interpretation—"Glad that you brought him in today - it sounds like Friskie and you had a tough morning."

     • Hypothesis test—"Given your recent experience with Snowball, I'm wondering if that's what you're worried about with Friskie."

Empathy is the fourth of the critical communication skills. This is different from but often confused with sympathy. Empathy is the ability to see a problem form another person's position and communicate that undertstanding to them. Empathy statements name and appreciate the person's predicament. Examples include:

     • Being seen: "I can see how hard it is to make this decision"

     • Being heard: "It must have been difficult for you raise this concern with me."

     • Being accepted: "It sounds like you did all that you could for Barney"

Empathy can be communicated in four primary ways:

     • Non-judgmental: "You were caught between a rock and a hard place."

     • Normalize: "I think anyone who loves their animal the way you do would have reacted that way."

     • Use appropriate self-disclosure: "This was one of the most difficult decisions that I had to make as well."

     • Non-verbal empathy

Communication can also be improved through an understanding of the different styles of communication. There are a number of assessments available to analyze this—the one use by the NCVEI classifies individuals as: sensors, intuitors, thinkers and feelers.

Sensors are direct and tough in their communication and talk about facts. Intuitors like loose, unstructured communication with many options. Thinkers are very objective, logical and business like in their communications. And feelers are casual, relaxed and friendly in their communications and are, as the name implies, concerned about feelings.

Successful communication means talking to others in their style, not yours. For example, you would say different things to a sensor in a post-dental follow-up call then you would a feeler:

     • Sensor—"Fluffy's recovered very well following her dental and will be ready to go home at 4pm."

     • Feeler—"Fluffy's a little woozy after her dental but her mouth is feeling much better since we pulled those teeth."

Additional information on effective communication as well as a communication style assessment is available on the NCVEI website—www.ncvei.org.