Improving Care Through Physicians’ Communication Skills

The Doctors Company Foundation funds the development of three standardized patient (SP) encounters to improve hospitalist communication skills

Grantee Profile

Mount Sinai Hospital is a 1,171-bed, tertiary-care teaching facility in New York City acclaimed internationally for excellence in clinical care.

Overview/Outcomes

• Mount Sinai Hospital received a grant of $59,174 to develop three SP training modules for assessing and improving discussions between their 23 attending hospitalists and patients/caregivers.
• Hospitalists encountered SPs in three key scenarios: one at daily rounds, one upset over a missed diagnosis, and one at discharge, when the potential for errors and miscommunication is greatest.
• The training goal was to decrease the variability within physicians’ approaches, and thereby increase patient safety, patient compliance, patient satisfaction, and patient health literacy.
• Mount Sinai published an article in the July 2017 issue of the Journal of Hospital Medicine (Chang D, Mann M, Sommer T, et al. Using standardized patients to assess hospitalist communication skills. J Hosp Med. 2017;12(7):562-566). Post-test study results demonstrated that hospitalists had an increased level of confidence in their bedside manner, patient satisfaction skills, and high-quality discharge discussion skills.
• The original training of 23 hospitalists has expanded into a program in which 1,845 residents in various specialties have been trained between 2013 and 2017.

The Challenge: Meeting Patients—at Crucial Points of Care

The ability to communicate complex information with patients is fundamental to a physician’s competence. Yet hospitalists face distinct communication challenges—they have usually never met patients or their families before beginning conversations at crucial points of care. Hospitalists also face time pressures and the demand to mesh information from multiple sources.

In 2016, The Doctors Company Hospitalist Closed Claims Study found that across U.S. hospitals, communication gaps were a major cause of both harm to patients and claims against providers.

Previously, in 2011, Mount Sinai clinicians and staff insightfully recognized that hospitalists at their teaching institution played a crucial role not only as caregivers, but as teachers of medical residents and students, and that “[h]aving hospitalists actively utilize key skills and behaviors will reinforce those concepts to all learners at our institution.”

Adapting SP Methodology for Hospitalists

The Morchand Center for Clinical Competence at the Icahn School of Medicine at Mount Sinai uses SP methodology to train students, residents, and other healthcare professionals to communicate with patients in the thoughtful and sensitive manner necessary for a successful doctor-patient relationship.

SPs have been used to assess communication skills in undergraduate medical education, but to the knowledge of the authors, no published studies—prior to Mount Sinai’s—have described the use of SPs in assessing practicing physicians’ communication skills.

Mount Sinai clinicians and staff revised two existing SP encounters to be more relevant for hospitalists and address more complex patient issues. In addition, they created and piloted a third patient encounter focusing on a conversation with a patient and his daughter, both unhappy because of a previously missed lung mass that was now found to be cancer.

Strengthening Doctors’ Communication Skills to Improve Patient Outcomes

All 23 hospitalists at Mount Sinai participated in testing and training to improve their patient communication skills during three key patient encounters: daily rounding, discharge, and interacting with a difficult patient.

Patient satisfaction data was collected as a baseline for each physician using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), a survey that is required by the Centers for Medicare and Medicaid to be sent by hospitals to all adult inpatients after discharge. Then, after each SP encounter, hospitalists reviewed their videotapes and received feedback from their SPs based on a checklist with three core domains: Listen, Courtesy and Respect, and Explain. These domains were derived from the three questions in the HCAHPS survey that relate to doctors (how often did doctors treat you with courtesy and respect, how often did doctors listen carefully to you, and how often did doctors explain things in a way you could understand) and AIDET®, an effective communication skills training protocol that the hospitalists had been trained on.

Hospitalists performed significantly better in the Listen domain than in the Explain domain or the Courtesy and Respect domain. From the Explain domain, the checklist items that were most commonly performed inadequately were summarizing information at the end of the encounter, teach back (asking patients to restate what they’ve learned to check for understanding), encouraging additional questions, managing up themselves and the team (giving a positive impression of others on the healthcare team to the patient), setting expectations about length of stay, and timing of tests.

By applying what they learned from their SP encounters about communication skills, hospitalists can improve patient comprehension, which can improve patient follow-though on discharge instructions and reduce risk of readmission, thus improving patient outcomes while reducing costs.

In the paper published in the July 2017 issue of Journal of Hospital Medicine, the study authors summarized: “Hospitalists must create rapport and communicate large amounts of information in a short amount of time without having a prior relationship with the patient. High-quality communication can improve satisfaction and compliance.”

Assessing Results, Sharing Takeaways

The study authors noted a trend: Hospitalists who started out as the lowest performers showed the greatest improvement. The study authors found that hospitalists had an increased level of confidence in their bedside manner, patient satisfaction skills, and high-quality discharge discussion skills.

Besides the article published in the Journal of Hospital Medicine, preliminary results were shared during an oral presentation at the 2013 International Conference on Communication in Healthcare (ICCH).

Now, the Morchand Center continues to offer the discharge and rounding SP trainings, along with others developed separately from the Foundation grant, for residents from hospitals all over New York City.

Terry Sommer, director of the Morchand Center, reported that the greatest learning benefits for hospitalists and residents alike came from the chance to watch their own SP videos, in addition to receiving direct feedback from the SPs. In 2016, 94.5 percent of residents agreed or strongly agreed with the statement, “The SP feedback session was helpful to me.” About the training, she said, “The residency program directors are champions of it now . . . We hope the training will stick.”

This positive outcome of ongoing training is consistent with the original authors’ aspiration that hospitalists, as team leaders and role models, could set examples and use their takeaways from this training to empower others in the healthcare system at large to communicate with their patients better.