A growing emphasis on physician—patient communication in medicine and medical education is reflected in international consensus statements,1,2 guidelines for medical schools,3–6 and standards for professional practice and education.7–12 In May 1999, with work in these areas and related research13–17 as a backdrop, 21 people from medical schools, residency programs, continuing medical education providers, and prominent medical educational organizations in North America convened for three days in Kalamazoo, Michigan, for the Bayer—Fetzer Conference on Physician—Patient Communication in Medical Education. The aim of this invitational conference was to identify and specifically articulate ways to facilitate communication teaching, assessment, and evaluation.
The group used an open-ended, iterative process to identify and prioritize topics for discussion. A major topic of interest to the entire group was delineating a set of essential elements in physician—patient communication. Participants expressed three goals for the discussion:
- Reaching consensus on a “short list” of elements that would characterize effective communication in several clinical contexts.
- Providing tangible examples of skill competencies that would be useful for licensing bodies, organizations that accredit medical schools and residency programs, and directors of medical education programs at all levels.
- Ensuring that the product generated by the group would be evidence based and appropriate for teaching, assessment, and evaluation.
Since the group included architects and representatives of five currently used models of doctor—patient communication, participants agreed that the goals might best be achieved through review and synthesis of the models' essential elements. Toward that end, brief presentations were delivered about each of the five models:
- Bayer Institute for Health Care Communication E4 Model18
- Three Function Model/Brown Interview Checklist19
- The Calgary—Cambridge Observation Guide20
- Patient-centered clinical method21
- SEGUE Framework for teaching and assessing communication skills22
Each presentation included an explicit description of the model, encompassing its research base, overarching views of the medical encounter, and current applications. After discussion of the models, attendees from the Accreditation Council for Graduate Medical Education (ACGME), the CanMEDS 2000 Project, the Educational Commission for Foreign Medical Graduates (ECFMG), and the Macy Health Communication Initiative provided information about their efforts to develop criteria for teaching and evaluating physician—patient communication. The group then began looking for commonalities among the models as well as points of departure. This process was enriched by the number and diversity of organizations represented by conference participants.
THE ESSENTIAL ELEMENTS
Consensus on the essential elements of physician—patient communication was reached by using the three goals outlined above to guide and ground discussion. The group's perspective on essential elements is consistent with the task approach, a concept that has been well supported in communication skills teaching since the early 1980s.3,18–25 As noted by Makoul and Schofield,2 “focusing on tasks provides a sense of purpose for learning communication skills. The task approach also preserves the individuality of [learners] by encouraging them to develop a repertoire of strategies and skills, and respond to patients in a flexible way.”
By identifying specific communication tasks, the group worked to highlight behaviors that are embedded in existing consensus statements, guidelines, and standards. While the list is by no means exhaustive, the intent was to make it easier for people working in this area to identify not only the key tasks, but the relevant knowledge, skills, and attitudes as well. References for the supporting research are listed and discussed in a number of texts.20,21,23–28
Build a Relationship: The Fundamental Communication Task
A strong, therapeutic, and effective relationship is the sine qua non of physician—patient communication.29,30 The group endorses a patient-centered, or relationship-centered, approach to care, which emphasizes both the patient's disease and his or her illness experience.31,32 This requires eliciting the patient's story of illness while guiding the interview through a process of diagnostic reasoning. It also requires an awareness that the ideas, feelings, and values of both the patient and the physician influence the relationship.2,15,33 Further, this approach regards the physician—patient relationship as a partnership, and respects patients' active participation in decision making.34–36 The task of building a relationship is also relevant for work with patients' families and support networks. In essence, building a relationship is an ongoing task within and across encounters: it undergirds the more sequentially ordered sets of tasks identified below.
Open the Discussion
- Allow the patient to complete his or her opening statement
- Elicit the patient's full set of concerns
- Establish/maintain a personal connection
- Use open-ended and closed-ended questions appropriately
- Structure, clarify, and summarize information
- Actively listen using nonverbal (e.g., eye contact) and verbal (e.g., words of encouragement) techniques
Understand the Patient's Perspective
- Explore contextual factors (e.g., family, culture, gender, age, socioeconomic status, spirituality)
- Explore beliefs, concerns, and expectations about health and illness
- Acknowledge and respond to the patient's ideas, feelings, and values
- Use language the patient can understand
- Check for understanding
- Encourage questions
Reach Agreement on Problems and Plans
- Encourage the patient to participate in decisions to the extent he or she desires
- Check the patient's willingness and ability to follow the plan
- Identify and enlist resources and supports
- Ask whether the patient has other issues or concerns
- Summarize and affirm agreement with the plan of action
- Discuss follow-up (e.g., next visit, plan for unexpected outcomes)
This outline of essential elements in effective physician—patient communication provides a coherent framework for teaching and assessing communication skills, determining relevant knowledge and attitudes, and evaluating educational programs. In addition, the outline can inform the development of specific standards in this domain. Most of the elements included in this document are present in each of the five models examined during the process of consensus building. A major strength of the outline is that it represents the collaboration and consensus of individuals with a variety of backgrounds and interests in medical education. Further, the basic outline can be tailored to meet the needs of different specialties, settings, and health problems. Conscientious efforts to address these essential elements across practice settings will help increase the efficiency and effectiveness of physician—patient communication,37 enhance patient and physician satisfaction,38,39 and improve health outcomes.40
1. Simpson M, Buckman R, Stewart M, et al. Doctor—patient communication: the Toronto consensus statement. BMJ. 1991;303:1385–7.
2. Makoul G, Schofield T. Communication teaching and assessment in medical education: an international consensus statement. Patient Educ Couns. 1999;137:191–5.
3. Association of American Medical Colleges. Medical School Objectives Project, Report III. Contemporary Issues in Medicine: Communication in Medicine. Washington, DC: Association of American Medical Colleges, 1999.
4. Workshop Planning Committee: Consensus statement from the Workshop on the Teaching and Assessment of Communication Skills in Canadian Medical Schools. Can Med Assoc J. 1992;147:1149–52.
5. General Medical Council. Tomorrow's Doctors: Recommendations on Undergraduate Medical Education. London, U.K.: General Medical Council, 1993.
6. Bass EB, Fortin AH 4th, Morrison G, Wills S, Mumford LM, Goroll AH. National survey of clerkship directors in internal medicine on the competencies that should be addressed in the medicine core clerkship. Am J Med. 1997;102:564–71.
7. Liaison Committee on Medical Education. Functions and Structure of a Medical School. Washington, DC: Liaison Committee on Medical Education, 1998.
8. Klass D, De Champlain A, Fletcher E, King A, Macmillan M. Development of a performance-based test of clinical skills for the United States Medical Licensing Examination. Fed Bull. 1998;85:177–85.
9. Whelan GP. Educational Commission for Foreign Medical Graduates: clinical skills assessment prototype. Med Teach. 1999;21:156–60.
10. Committee for Review of Program Requirements. Agenda Book. Chicago, IL: Accreditation Council for Graduate Medical Education Accreditation, 1999.
11. Communications Self-Evaluation Process (COM-SEP) Committee. Minutes. Philadelphia, PA: American Board of Internal Medicine, 1999.
12. Tate P, Foulkes J, Neighbour R, Campion P, Field S. Assessing physicians' interpersonal skills via videotaped encounters: a new approach for the Royal College of General Practitioners Membership Examination. J Health Comm. 1999;4:143–52.
13. Novack DH, Volk G, Drossman DA, Lipkin M Jr. Medical interviewing and interpersonal skills teaching in U.S. medical schools. Progress, problems, and promise. JAMA. 1993; 269:2101–5.
14. Hargie O, Dickson D, Boohan M, Hughes K. A survey of communication skills training in UK schools of medicine: present practices and prospective proposals. Med Educ. 1998; 32:25–34.
15. Makoul G, Curry RH, Novack DH. The future of medical school courses in professional skills and perspectives. Acad Med. 1998;73:48–51.
16. Boon H, Stewart M. Patient—physician communication assessment instruments: 1986 to 1996 in review. Patient Educ Couns. 1998; 35:161–76.
17. Ong LML, deHaes JCJM, Hoos AM, Lammes FB. Doctor—patient communication: a review of the literature. Soc Sci Med. 1995;40:903–18.
18. Keller V, Carroll JG. A new model for physician—patient communication. Patient Educ Couns. 1994;23:131–40.
19. Novack DH, Dube C, Goldstein MG. Teaching medical interviewing: a basic course on interviewing and the physician—patient relationship. Arch Intern Med. 1992;152:1814–20.
20. Kurtz S, Silverman J, Draper J. Teaching and Learning Communication Skills in Medicine. Abingdon, Oxon, U.K.: Radcliffe Medical Press, 1998.
21. Stewart M, Belle Brown J, Weston WW, McWhinney IR, McWilliam CL, Freeman TR. Patient-Centered Medicine: Transforming the Clinical Method. Thousand Oaks, CA: Sage, 1995.
22. Makoul G. Communication research in medical education. In: Jackson L, Duffy BK (eds). Health Communication Research: A Guide to Developments and Directions. Westport, CT: Greenwood Press, 1998:17–35.
23. Riccardi VM, Kurtz SM. Communication and Counseling in Health Care. Springfield, IL: Charles C Thomas, 1983.
24. Pendleton D, Schofield T, Tate P, Havelock P. The Consultation: An Approach to Learning and Teaching. Oxford, U.K.: Oxford University Press, 1984.
25. Cohen-Cole SA. The Medical Interview: The Three-Function Approach. St. Louis, MO: Mosby Year Book, 1991.
26. Lipkin M Jr, Putnam SM, Lazare A (eds). The Medical Interview: Clinical Care, Education, and Research. New York: Springer-Verlag, 1995.
27. Silverman J, Kurtz S, Draper J. Skills for Communicating with Patients. Abingdon, Oxon, U.K.: Radcliffe Medical Press, 1998.
28. Stewart M, Roter D. Communicating with Medical Patients. Thousand Oaks, CA: Sage, 1989.
29. Novack DH. Therapeutic aspects of the clinical encounter. J Gen Intern Med. 1987;2:346–55.
30. Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract. 1998;47:213–20.
31. Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196:129–36.
32. Kleinman A. The Illness Narratives: Suffering, Healing and the Human Condition. New York: Basic Books, 1988.
33. Novack DH, Suchman AL, Clark W, Epstein RM, Najberg E, Kaplan C. Calibrating the physician: personal awareness and effective patient care. JAMA. 1997;278:502–9.
34. Williams GC, Freedman ZR, Deci EL. Supporting autonomy to motivate patients with diabetes for glucose control. Diabetes Care. 1998;21:1644–51.
35. Kaplan SH, Gandek B, Greenfield S, Rogers W, Ware JE. Patient and visit characteristics related to physicians' participatory decision-making style. Results from the Medical Outcomes Study. Med Care. 1995;33:1176–87.
36. Gudagnoli E, Ward P. Patient participation in decision making. Soc Sci Med. 1998;47:329–39.
37. Stewart MA. Effective physician—patient communication and health outcomes: a review. Can Med Assoc J. 1995;152:1423–33.
38. Williams S, Weinman J, Dale J. Doctor—patient communication and patient satisfaction: a review. Fam Pract. 1995;15:480–92.
39. Suchman AL, Roter D, Green M, Lipkin M Jr. Physician satisfaction with primary care office visits. Collaborative Study Group of the American Academy on Physician and Patient. Med Care. 1993;31:1083–92.
Participants in the Bayer–Fetzer Conference on Patient—Physician Communication in Medical Education, May 1999
Patrick H. Brunett, MD
Assistant Professor of Emergency Medicine, Oregon Health Sciences University; member of Society for Academic Emergency Medicine
Thomas L. Campbell, MD
Professor of Family Medicine and Psychiatry, University of Rochester School of Medicine; member of Society of Teachers of Family Medicine; Advisory Council, Bayer Institute for Health Care Communication
Kathleen Cole-Kelly, MS, MSW
Associate Professor of Family Medicine, Case Western Reserve University School of Medicine; Director of Curriculum and Faculty Development at Case Western for the Macy Health Communication Initiative
Deborah Danoff, MD
Assistant Vice President, Division of Medical Education, Association of American Medical Colleges
Robert Frymier, MD
National Director, Educational and Partnerships Division, Veterans Affairs Learning University; Associate Professor of Family Medicine, Case Western Reserve University School of Medicine
Michael G. Goldstein, MD
Associate Director, Clinical Education and Research, Bayer Institute for Health Care Communication; Adjunct Professor of Psychiatry, Brown University School of Medicine
Geoffrey H. Gordon, MD
Associate Director, Clinical Education and Research, Bayer Institute for Health Care Communication; Assistant Clinical Professor of Medicine and Psychiatry, Yale University School of Medicine
Daniel J. Klass, MD
Director, Standardized Patient Project, National Board Medical Examiners
Suzanne Kurtz, PhD
Professor of Communication, Faculties of Medicine and Education, University of Calgary
Jack Laidlaw, MD
Head, Division of Education, Cancer Care Ontario; Advisory Council, Bayer Institute for Health Care Communication
Forrest Lang, MD
Vice Chair, Department of Family Medicine, East Tennessee State University; member of Society of Teachers of Family Medicine
Anne-Marie MacLellan, MD
Faculty of Medicine, McGill University; member of Association of Canadian Medical Colleges
Gregory Makoul, PhD
Associate Professor and Director, Program in Communication and Medicine, Northwestern University Medical School
Steven Miller, MD
Director, Pediatric Medical Student Education, Columbia University School of Medicine; Council on Medical Student Education in Pediatrics
Dennis Novack, MD
Professor of Medicine and Associate Dean for Education, Medical College of Pennsylvania Hahnemann School of Medicine; member of American Academy on Physician and Patient
Elizabeth A. Rider, MSW, MD
Clinical Instructor in Pediatrics and Instructor in Medical Education, Harvard Medical School; Office of Educational Development, Harvard Medical School
Frank A. Simon, MD
Director, Division of Graduate Medical Education, American Medical Association
David Sluyter, EdD
Vice President for Education, Fetzer Institute
Susan Swing, PhD
Director of Research, Accreditation Council for Graduate Medical Education
Wayne Weston, MD
Professor of Family Medicine, University of Western Ontario; member of College of Family Physicians of Canada
Gerald P. Whelan, MD
Vice President for Clinical Skills Assessment, Educational Commission for Foreign Medical Graduates
40. Greenfield S, Kaplan S, Ware JE. Expanding patient involvement in care: effects on patient outcomes. Ann Intern Med. 1985;102:520–8.