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Golden Rules

Communication Skills Training Vital to Health Care

Weinstein, Barbara E. PhD

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doi: 10.1097/01.HJ.0000651572.75236.88
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A cornerstone of patient safety and quality health care, effective communication allows patients to participate fully in their care, thereby facilitating clinical decision-making. According to the Joint Commission Comprehensive Accreditation Manual for Hospitals, for communication to be effective, it must take place in a manner appropriate to one's age, understanding, and communication abilities.1 Furthermore, medical information, when provided, must be complete, accurate, timely, unambiguous, and understood by the patient. The standard is clear: When a patient understands treatment and services, his or her health care needs can be optimally met.

iStock/D-Keine, audiology, health, communication.

Communication skills training, which is becoming a priority in health care, aims to optimize clinician communication skills so patients’ needs, priorities, and values can be met.2 A speaker must ensure from the outset that the patient can understand verbally delivered information, especially in noisy health care settings. Despite emerging data linking health care outcomes to effective communication, the importance of hearing and understanding does not seem to be part of the conversation about competence in communication in medical settings.

EVIDENCE IN HOSPITAL READMISSION DATA

The evidence is sound: Poor communication in health care settings has economic ramifications and impacts perceptions of health care quality.3 According to recent studies, 30-day hospital readmissions are higher and treatment adherence lower when a patient's hearing status is compromised.2,4,5 With regard to the former, Chang and colleagues analyzed all-cause readmission data from the Medicare Current Beneficiary Survey (MCBS), a nationally representative rotating panel survey of individuals aged 65 and over.4 Readmission was defined as admissions to an acute care hospital within 30 days of index discharge, and difficulty communicating with medical personnel was based on self-reported hearing difficulty (with or without hearing aid use). Difficulty communicating was associated with a substantially higher risk of 30-day hospital readmission. About 11.6 percent of respondents characterized their hearing difficulties as being sufficiently severe that they had trouble communicating with their doctor or other medical personnel; those who reported trouble communicating had, on average, 32 percent greater odds of hospital readmission. In another study that examined U.S. Medicare beneficiary data, Mahmoudi, et al., found that self-reported hearing aid use reduced emergency department visits, hospitalizations, and the number of nights spent in the hospital.6 Taken together, the data above suggest that hearing status is critical to the exchange of information and that optimizing communication may reduce some of the barriers posed by hearing loss.

TRAINING MODEL

Mandatory communication skills training for clinicians has been endorsed by a number of organizations, including the National Academy of Medicine, the National Academy of Sciences, and the World Health Organization.2 Interestingly, the communication skills to which these organizations refer focus on: (a) ensuring that priorities and values articulated by the patient are adequate, (b) reinforcing the importance of attending to patient emotions, (c) ensuring that treatment recommendations are patient-centered, (d) emphasizing the need to use plain language rather than medical jargon, and (e) highlighting the value of providing an opportunity for patients to speak and be heard as people rather than as patients.2 Regarding patient emotions, the importance of allowing for silence immediately after delivering difficult news tends to be underscored, as well as the need to respond to patient emotions and express commitment to the patient. The American Society of Clinical Oncology (ASCO) recently published a set of guidelines to support strong physician-patient relationships and patient-centered care.7 Each recommendation entails the clinician's understanding of a patient's preferences, values, and needs, and in turn the patient's understanding of his or her prognosis, treatment options, appointment schedules, etc. The guidelines stress bidirectional communication, and list barriers to effective communication, including low health literacy. Clearly, the ability to hear and understand is at the heart of effective communication and implicit in the ASCO guidelines. However, the guidelines do not include a mechanism for ensuring core communication skills on the part of the patient, namely the ability to hear and understand the clinician.

Back, et al., emphasized the importance of developing a cadre of skilled communication teachers to provide technical assistance and pedagogical content knowledge.2 However, strategies for ruling out sensory loss, optimizing audibility, and communicating with patients with hearing loss were not mentioned in their discussion of communication competence in health care. Again, we see a disconnect: Hearing is a first-order event within the communication speech chain, yet its importance is rarely mentioned and appears to be taken for granted.

My colleagues and I conducted a structured literature search on the published medical literature on doctor-patient communication with patients 60 years of age and older.8 Our search within PubMed focused on original studies on physician-patient communication with older patients published after 2000.8 Of the 409 papers from the initial search and the 67 studies incorporated into our systematic review, only 15 studies (22.4%) mentioned hearing, and none mentioned hearing impairment as a barrier to communication. It is no wonder that people with hearing loss have lower ratings of physician-patient communication and health care quality compared with those without hearing loss.3

AUDIOLOGISTS AS COMMUNICATION ADVOCATES

The patients’ right to receive accurate and comprehensible information about their health, as indicated in the Consumer Bill of Rights and Responsibilities Act, indicates that hearing care professionals play an important role in ensuring effective communication in medical settings.9 I would like to see us work interprofessionally to gain recognition as communication experts and go-to resources for people with hearing loss across the continuum of health care—from acute and long-term to palliative care.

Back, et al., suggested that communication skills training should be modular and configurable to address specific system needs.2 They argued for metrics to assess clinician communication performance using the Consumer Assessment of Healthcare Providers and Systems (CAHPS), a family of surveys that ask patients about the quality of their health care experience. Interestingly, the first two questions on the 2017 Medicare CAHPS survey relate to hearing aid use, and one question asks how often the respondent's personal doctor explained things in a way that was easy to understand.10

Audiologists should encourage their patients with hearing loss to wear hearing aids or use hearing assistance technology during health care encounters. We should urge patients to confirm that their health care provider has explained what they need to know in a manner that they understand. This is especially important for vulnerable populations (e.g., when learning about a cancer or dementia diagnosis) since the stress associated with such an encounter will likely exacerbate the effort necessary to listen, diverting energy away from cognitive reserves such as memory storage for new information.11 As part of routine counseling sessions, remind patients that their understanding of their health issues will promote collaborative physician-patient communication, enable their physician to be more supportive, and help optimize their adherence to the treatment processes.12 Let's begin with bottom-up advocacy and interprofessional dialogue about the importance of hearing and understanding and clinicians’ communication skills training to better serve patients with hearing loss.

REFERENCES

1. Blustein, J., Wallhagen, M., Weinstein, B. & Chodosh, J. (2019). Time to take hearing loss seriously. The Joint Commission Journal on Quality and Patient Safety (In press).
2. Back, A., Fromme, E., & Meier, D. (2019). Training clinicians with communication skills needed to match medical treatments to patient values. JAGS. 67:S435-S441.
3. Mick P, Foley DM, Lin FR. (2014). Hearing loss is associated with poorer ratings of patient-physician communication and healthcare quality. J Am Geriatr Soc. 62:2207-2209.
4. Chang, J., Weinstein, B., Chodosh, & Blustein (2018). Hospital readmission risk for patients with self-reported hearing loss and communication trouble. JAGS. J Am Geriatr Soc. 66: 2227-8.
5. Reed N., Deal J., Yeh, C., Karvetz, A., Wallhagen M, & Lin F. (2019). Trends in health care costs and utilization associated with untreated hearing loss over 10 years. JAMA Otolarygol. 2019;145(1):27-34.
6. Mahmoudi, E., Zazove, P., Meade, M, et al., (2018). Association between hearing aid use and health care use and cost among older adults with hearing loss. JAMA Otolaryngology Head Neck Surg. 144: 498-505.
7. Gilligan, T., Coyle, N., Frankel, R., et al., (2017). Patient-Clinician Communication: American Society of Clinical Oncology Consensus Guideline. J Clin Oncol. 35:3618-3632.
8. Cohen, J., Blustein, J., Weinstein, B., Chodosh, J., et al., (2017). Studies ofPhysician-Patient Communication with Older Patients: How Often is Hearing Loss Considered? A Systematic Literature Review. Journal American Geriatrics Society. doi:10.1111/jgs.14860.
9. AHRQ (1997). Agency for Health Care Research and Quality, Rockville, MD. Consumer Bill of Rights and Responsibilities.
10. Medicare CAHPS (2017). http://doi.nv.gov/uploadedFiles/doi.nv.gov/Content/Insurers/Life_and_Health/CAHPS%20Survey%20Report.pdf. Retrieved October 5, 2019.
11. Pichora-Fuller, K. (2016). How Social Psychological Factors May Modulate Auditory and Cognitive Functioning During Listening. Ear and Hearing. 37: 92S-100S.
12. Ha JF & Longnecker H. (2010). Doctor-patient communication: a review. Ochsner Journal. 10: 38-43.
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