Many physicians prioritize quality of care over patient communication because they equate right care with a positive patient experience—but unfortunately, that's often not how patients experience their care. Dr. Jay Kaplan, Medical Director of Care Transformation at LCMC Health and former Medical Director of Studer Group, argues that when physicians push patient-centered communication to the bottom of their (extremely long) to-do list, they miss an opportunity to improve patient outcomes and strengthen their personal relationship with patients—the reason they probably entered medicine in the first place.
Dr. Kaplan has spent more than 25 years collaborating with health care leaders and physicians to improve physician-patient communication across the United States and Canada. We spoke with Dr. Kaplan to get his take on how organizations can change physicians' mindsets on patient communication.
Question: How did you decide to focus your career on improving patient communication?
Jay Kaplan: In 1995, my CEO called me into his office and said, "I know you think you run a great ED, but our patients don't think so. You're in the 50th percentile for patient satisfaction. I want 90th percentile." Even 30 years ago, he recognized that better patient communication leads to better clinical outcomes. Within a year, our patient experience scores were in the 90th percentile, patient visits grew by 10% per year over a decade, and our ED nurse vacancy rate of about 20% shifted to a waiting list of staff who wanted to work with us.
In my experience, physicians and nurses go into health care to help people, but today health care has become so task-oriented: "I need to see X number of patients; I need to get my documentation done; I need to answer all the messages in my inbox," etc. Along the way, we've lost that connection to our patients and to our sense of purpose. So, after leading multiple ED turnarounds for my system, I dedicated the next 15 years to improving patient communication in EDs, hospitals, and clinics across the country in hopes of restoring the physician-patient relationship.
Q: What do organizations often get wrong in their efforts to improve patient communication?
Kaplan: First, organizations say, "We're going to put patients first," without simultaneously communicating to their staff, "We're going to focus on creating a great place for you to work." In my experience, the organizations that recognize that the two go hand-in-hand achieve better outcomes for both patients and clinicians.
Second, when leaders attempt to implement patient communication initiatives, they need to present it as an opportunity to improve patient outcomes and clinical quality rather than the additional performance metric of "patient satisfaction." In many cases, leaders focus more on what clinicians need to do and how to do it rather than leading with why it's important to improve communication in the first place. Studies show better communication between doctors, nurses, and patients leads to better clinical outcomes, improved patient safety, and an enhanced patient experience. And a better patient experience helps hospitals and physician practices grow. It's also a way for clinicians to feel more professionally fulfilled. So, when we do give clinicians feedback on how patients experience interactions with them, we need to present it as an educational opportunity rather than making them feel criticized or judged.
Third, organizations ask doctors and nurses to make too many changes at once. If you ask someone to do one thing differently, there's about an 80% likelihood that the behavior will change—and stick in daily practice. If you ask them to do two things differently at the same time, that likelihood drops to 50%. If you ask them to do three new things differently, it drops to one-third.
Q: You developed the high-performing clinician self-tests to make improving patient communication a manageable ask for clinicians. How did you land on this solution?
Kaplan: Traditionally, organizations use certain mnemonics to improve communication. One of the most prevalent is AIDET®, and while it's a good mnemonic, it can easily turn into just another task or another box for clinicians to check. I've heard many clinical leaders say, "Did you do your AIDET?" instead of "Did you connect with the patient?"
Recognizing this, I adapted the AIDET® mnemonic and created the R.T.R. card, which stands for "Relationship-Task-Relationship." When you first walk in the room, it's about establishing a relationship with the patient, then you do your tasks such as taking a history and performing the physical, and at the end it's about the relationship again.
As you mentioned, I also developed the clinician self-tests to serve as an easy-to-use tool for clinicians to improve their communication with patients. This test includes a list of 12 actionable behaviors to improve patient communication and takes less than two minutes for clinicians to fill out. They are asked to rate themselves on how often they do each behavior—never, sometimes, usually, or always. They then pick one behavior that they are not an "always" on and commit to doing that behavior with every patient for one month. Over the course of the month, it becomes a habit. For example, I had a hospitalist who told me, "I never used to sit down with my patients; now, I feel rude when I don't." In my experience, I've found that prioritizing one behavior rather than trying to hardwire multiple at one time leads to much higher rates of clinician adoption.
Q: Knowing that physicians experiencing burnout have lower Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, what do you recommend physician executives do to support their medical staff in navigating this challenge?
Kaplan: As I mentioned before, physicians need to know that organizational leadership values them just as much as their patients. A recent survey of more than 15,000 physicians showed that over 42% reported feeling burned out. Because clinician burnout impacts communication, we need to start addressing the two together. One of the ways we can do this is to prioritize physician well-being and engagement. Let's refer to a simple three-component model of clinician well-being:
- Create an organizational culture of clinician and staff well-being and engagement. For example, a colleague of mine, a chief experience officer for a large health system on the east coast, believes team engagement and a supportive environment for doctors and nurses is the foundation for quality and patient experience. By focusing efforts there, her health system has seen improved clinical quality, patient safety, and patient experience, as well as decreased staff turnover and markedly improved morale.
- Foster personal resilience. Organizations can create programs to help physicians and staff eat better and exercise more, encourage them to do mindfulness exercises and get more sleep. The barrier here is building in the time and commitment and integrating personal resilience into clinician workflow. The major cause of burnout is not a deficit in personal resilience, but it's more related to organizational culture and the work environment itself, which brings us to …
- Prioritize efficiency of practice solutions. The average primary care doctor goes home at the end of a long day of seeing patients and spends one to two hours on EHR documentation. This "pajama time" interferes with physicians' connection to their families and their own personal downtime. It's important for organizations to look at the efficiency of practice solutions out there to streamline physician workflow.
Q: What's your advice to physician leaders whose medical staff is trying to balance recording the patient interaction in real-time with creating a personal relationship with patients?
Kaplan: The problem is that we teach physicians how to use software programs for documentation of clinical care, but we don't teach them how to use the computer in the presence of patients. We need to teach physicians about how they can connect with patients even as they utilize the computer for medical record documentation, or implement other solutions, such as medical scribes.
For example, my friend's cardiologist documents during the visit by using a dictation program. By speaking his notes—rather than just typing with the EHR—the cardiologist was able to get his documentation done during the visit and continue to educate and build a relationship with my friend.
The takeaway is that whether it's through dictation software, scribes, medical assistant support, etc., our focus should be on helping physicians seamlessly incorporate technology into the patient visit.
Want to learn more about improving patient communication?
For the full suite of ready-to-use patient communication strategies and tools, including those shared by Dr. Kaplan, check out The Physician Executive's Guide to Patient-Centered Communication. Dr. Kaplan can be reached at email@example.com.