The CAHPS Ambulatory Care

Improvement Guide
Practical Strategies for Improving Patient Experience

Section 6: Strategies for Improving Patient Experience with

Ambulatory Care

6.G. Training to Advance Physicians’ Communication Skills

Visit the AHRQ Website for the full Guide.

July 2017 (updated)

 The CAHPS Ambulatory Care Improvement Guide

Section 6: Strategies for Improving Patient Experience with Ambulatory Care

6.G. Training to Advance Physicians’ Communication Skills

6.G. TRAINING TO ADVANCE PHYSICIANS’ COMMUNICATION SKILLS

6.G.1. The Problem

People rarely complain about the technical aspects of the health care they receive
because—in the absence of an obvious error—patients are generally unable to judge
technical competence. However, they and only they are well-equipped to judge the
ability of clinicians to communicate with them effectively. Even though a clinician
explains a diagnosis, test result, or treatment option to a patient, if the person walks
away and does not understand the explanation, it has not been an effective
communication.

Poor communication can have a serious impact on health outcomes. Patients may not
provide the clinician with adequate information on their health or related concerns; they
may not comply with the physician’s orders—and in some cases, they may not even
understand what they have been told. According to a study at the University of Kansas
School of Medicine in Kansas City, patients’ reports of their understanding of the post-
discharge information and instructions they had received was significantly less than
what their doctors perceived. For example, while
the physicians thought that 89 percent of the
patients understood the potential side effects of
“With patient characteristics
their medications, only 57 percent of patients
and structural features of care
said that they understood. 1 taken into account, those with
In addition to affecting the patient’s experience the poorest-quality physician-
with health care, poor patient-physician
patient relationships in 1996
were 3 times more likely to
communication has important consequences for
leave the physician’s practice
medical practices. One study found that, in a
over the ensuing 3 years than
three-year period, 20 percent of Massachusetts
those with the highest-quality
state employees voluntarily left their primary relationships.”
care physician because of the poor quality of
their relationship, which was a function of trust, Safran DG, Montgomery JE, Chang
the patients’ sense that the physician knew them, H, et al. Switching doctors: Predictors
the level of communication, and personal of voluntary disenrollment from a
interaction. 2 Poor communication is also a primary physician’s practice. J Fam
contributing factor in a majority of malpractice Pract 2001;50(2):130-6.
suits. 3

_________________________________________________________________________________________________
1 Rogers C. Communications 101. Bulletin of the American Academy of Orthopaedic Surgeons 1999;47(5).

2Safran DG, Montgomery JE, Chang H, et al. Switching doctors: Predictors of voluntary disenrollment from a primary
physician’s practice. J Fam Pract 2001;50(2):130-6.
3 Flaherty M. Good Communication Cuts Risk. Physician’s Financial News 2002;20(2): s10-s11.

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 The CAHPS Ambulatory Care Improvement Guide

Section 6: Strategies for Improving Patient Experience with Ambulatory Care

6.G. Training to Advance Physicians’ Communication Skills

While the curriculums of most medical schools now include some form of training in
communications skills,1 this is a fairly recent phenomenon. Traditionally, medical
education has paid little attention to the skills that promote effective interactions with
patients. Most practicing physicians have not been taught to appreciate the patient’s
experience of illness; nor do they learn how to partner with patients and serve as a coach
or guide. As a result, they typically do not know how to communicate with patients in a
way that maximizes understanding and involvement in decision making, lets the patient
know that his or her concerns have been heard, and ensures that the care plan meets the
needs of the patient.

6.G.2. The Intervention

To compensate for this deficiency in medical education, numerous health plans and
medical groups are training clinicians in the communication skills they need—either
through in-house programs or through communications programs offered by outside
organizations. Most of these programs are optional, but a few organizations require the
participation of all doctors. In some organizations, the program is mandatory only for
those doctors who consistently receive low scores in this area.

The purpose of these programs is to improve providers’ effectiveness as both managers

of care and educators of patients. It is also believed that trained physicians may allocate
a greater percent of clinic-visit time to patient education, leading to increased patient
knowledge, better compliance with treatment, and improved health outcomes.

The most effective and efficient way of offering training in physician-patient

communication is in the form of seminars or workshops where you can cover many
strategies for improved communication in a relatively short period of time. Workshops
may also use case studies to illustrate the importance of communication and suggest
approaches to improving the physician-patient relationship.

For clinicians, workshops may serve multiple purposes, including increasing their
understanding of the physician’s roles, offering insight into the importance of connecting
with patients, and increasing confidence in their interviewing skills. In addition to basic
communication skills, the training can cover:

 History-taking skills
 Issues related to communicating across cultures
 Communicating with “problem” patients
 Interviewing techniques (including skills to help promote behavioral change)
 Empathic responses

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 The CAHPS Ambulatory Care Improvement Guide

Section 6: Strategies for Improving Patient Experience with Ambulatory Care

6.G. Training to Advance Physicians’ Communication Skills

Some programs also address

weaknesses in written Support in Improving Physician
communications, which can be a Communication
serious problem for clinicians who For help in implementing this strategy,
use e-mail to communicate with consider the following resources:
some patients. Group Health
Cooperative in Seattle, for example, Institute for Healthcare
offers a training curriculum on how Communication, New Haven, CT
to write e-mails to patients. http://www.healthcarecomm.org
The Institute for Healthcare Communication
Training in behavioral change (formerly the Bayer Institute) offers a variety
concepts can help physicians of workshops to help clinicians develop and
identify patients who are likely to be hone their communication skills. It also offers
receptive to their advice and books, videos, and practical guides on how to
guidance. To help physicians better improve communication.
understand the process of American Academy on Communication
behavioral change, some medical in Healthcare, Chesterfield, MO
groups and health plans are http://www.aachonline.org/
teaching physicians about the The American Academy on Communication in
Transtheoretical Model (see box Healthcare (AACH) is an interdisciplinary
below) and encouraging them to group of medical educators and clinicians that
identify where patients are in these share a common interest in patient-clinician
stages and to focus their educational communication and relationships, and
efforts on patients who are ready to psychosocial aspects of health care.
change.
The Foundation for Medical Excellence,
If patients are precontemplative, Portland, OR
physicians do not need to be http://www.tfme.org/
spending much time convincing The Foundation for Medical Excellence is a
them to stop or start a new non-profit foundation that sponsors a variety
behavior. But if they are of educational programs and consulting
contemplative, then the time services for licensed physicians. Its programs
required to coach them about things include education and research in physician-
they can do to adopt the desired patient communication.
behavior is well-spent. Motivational Interviewing Network of
Trainers, Fairfax, VA
http://motivationalinterviewing.org/
The Motivational Interviewing Network of
Trainers (MINT) is a non-profit organization
that provides training, coaching, and
consultation on the use of motivational
interviews to promote behavior change.

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 The CAHPS Ambulatory Care Improvement Guide

Section 6: Strategies for Improving Patient Experience with Ambulatory Care

6.G. Training to Advance Physicians’ Communication Skills

A Model of Behavioral Change

The Transtheoretical Model lays out five unique “Stages of Change:”
• Precontemplation is the stage in which there is no intention to change
behavior in the foreseeable future. Many individuals in this stage are unaware or
under-aware that a problem exists.
• Contemplation is the stage in which people are aware that a problem exists and
are seriously thinking about overcoming it but have not yet made a commitment
to take action.
• Preparation is a stage that combines intention and behavioral criteria.
Individuals in this stage are intending to take action in the next month and have
unsuccessfully taken action in the past year.
• Action is the stage in which individuals modify their behavior, experiences, or
environment in order to overcome their problems. Action involves the most overt
behavioral changes and requires considerable commitment of time and energy.
• Maintenance is the stage in which people work to prevent relapse and
consolidate the gains attained during action. For addictive behaviors, this stage
extends from six months to an indeterminate period past the initial action.
A full explanation of this model can be found at Cancer Prevention Research Center: Home of
the Transtheoretical Model. Detailed Overview. Available at:
http://web.uri.edu/cprc/detailed-overview/. Accessed July 31, 2017.

6.G.3. Example
One of the best-known examples of an in-house program to inculcate strong
communication skills in clinicians is the Thriving in a Busy Practice program developed
by Terry Stein, MD, at Kaiser Permanente. This comprehensive communications
curriculum strives to develop the ability of physicians to relate to patients effectively in
both routine and difficult settings. In particular, it is intended to help physicians learn
and practice techniques for dealing with difficult patient encounters. The workshops
address the issues that typically confront primary care physicians as well as guidance
pertinent for different specialists (such as emergency physicians).

Evaluations of this program have found a positive impact on the clinicians. One study
found that clinicians reported improved confidence in their ability to conduct effective
medical interviews and handle difficult situations. It also found that, after taking the
course, fewer clinicians reported frustration with patient visits (specifically, the percent
reporting frustration with 11 percent or more of patient visits fell from about half before
the course to about one-third afterwards). 4 However, the impact on patient satisfaction
_________________________________________________________________________________________________
4 Stein TS, Kwan J. Thriving in a busy practice: Physician-patient communication training. Eff Clin Pract 1999;2(2):63-70.

Available at: http://ecp.acponline.org/marapr99/thriving.pdf . Accessed July 7, 2017.

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 The CAHPS Ambulatory Care Improvement Guide

Section 6: Strategies for Improving Patient Experience with Ambulatory Care

6.G. Training to Advance Physicians’ Communication Skills

is not yet clear: One study found that the program had no impact, but noted that other
factors may have influenced that finding. 5

Read More About Improving Communication Skills

• American Medical Association. Section II: Resources Emphasizing
Communication Skills. In: Cultural Competence Compendium. Chicago, IL;
American Medical Association 1999: 89-106.
• Carrillo JE, Green AR, Betancourt JR. Cross-cultural primary care: A patient-
based approach. Ann Intern Med 1999 May 18;130(10):829-34.
• Coulter A. The Autonomous Patient: Ending Paternalism in Medical Care.
London: Nuffield Trust 2002.
• Jackson C. It Pays to Listen: The Importance of Doctor-Patient Communication.
Amer Med News 2001 May 21.
• Nelson AM, Brown SW. Improving Patient Satisfaction Now. New York, NY:
Aspen Publishers, Inc. 1997 April.
• Nigg CR, Burbank P, Padula C, et al. Stages of change across ten health risk
behaviors for older adults. Gerontologist 1999;39:473-82.
• Prochaska JO, Norcross JC, DiClemente C. Changing for Good. New York, NY:
William Morrow and Company, Inc.; 1994.
• Prochaska JO. Helping patients at every stage of change. Behavioral Approaches
to Addiction Journal 1992;1(1):2-7.
• Ranier SB, Daughtridge R, Sloane PD. Physician-patient communication in the
primary care office: A systematic review. J Am Board Fam Pract 2002;15(1):25-
38.

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5 Brown JB, Boles M, Mullooly J, et al. Effect of clinician communication skills training on patient satisfaction. A

randomized, controlled trial. Ann Intern Med 1999;131(11):822-9.

July 2017 6.G-5