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Patient Communication: What to Teach
What weve got here is a failure to
communicate.
Donn Pearce and Frank R. Pierson
Cool Hand Luke (screenplay)
T
he standards by which residents will
be evaluated in the future are chang-
ing. The American Board of Medi-
cal Specialties has adopted six general
competencies for all physicians [1]. These in-
clude medical knowledge, patient care, interper-
sonal and communication skills, professionalism,
practice-based learning and improvement, and
systems-based practice. Radiology educators
need to take a close look at these competencies
and determine what their implications may be for
the future of radiology. To that end, this article fo-
cuses on the third of the six general competen-
cies, interpersonal and communication skills. We
spend huge amounts of time training residents to
detect lesions, offer appropriate differential diag-
noses, and perform procedures, but little or no
time teaching them how to communicate with
patients. How can we prepare residents to be
more effective communicators throughout their
careers as practicing radiologists?
There are important reasons for all physi-
cians to be effective communicators. First, a
clear correlation exists between the quality of
communication and the level of patient satisfac-
Received December 8, 2000; accepted after revision January 17, 2001.
1
Department of Radiology, Indiana University School of Medicine, 702 Barnhill Dr., RI 1053, Indianapolis, IN 46202-5200. Address correspondence to R. B. Gunderman.
AJR 2001;177:4143 0361803X/01/177141 American Roentgen Ray Society
AJR:177, July 2001
Radiology Residents
tion [2]. Most patients assume that they are re-
ceiving technically competent care; the quality
of the patientphysician relationship is the ma-
jor determinant of their satisfaction. Moreover,
communication has been proven to affect pa-
tient outcomes [3]. For example, patients who
highly rate the quality of communication they
have with their physicians tend to require less
analgesia and enjoy higher functional status [4].
Communication is also a major factor in medi-
cal malpractice suits: Low-quality communica-
tion is a higher predictor of litigation than
adverse outcomes [5], and 70% of depositions
show evidence of faulty communication [6]. Fi-
nally, high-quality communication with patients
is associated with higher levels of career satis-
faction among physicians, indicating that efforts
to improve patientphysician communication
can benefit not only patients but also physicians
themselves [7].
Radiology residents must be given opportu-
nities to improve their communication skills.
Physician develop habits or styles of interact-
ing with patients, and those habits can be posi-
tively influenced by appropriate educational
experiences during their formative years. By
helping residents adopt effective habits of pa-
tient communication early in their training,
residency programs can improve patient care,
enhance career satisfaction, and enrich the fu-
ture of radiology itself. What follows is a dis-
cussion of six key characteristics of effective
Opinion
Richard B. Gunderman 1
communicatorstraits training programs
should aim to fosterand a list of 10 practical
techniques that radiology residents can be en-
couraged to implement as they interact on a
daily basis with patients.
Traits of Effective Communicators
Sensitivity
A resident was obtaining informed consent
from a parent for a complex interventional pro-
cedure her child was to undergo. After explain-
ing some of the more common complications,
the resident explicitly warned the mother that
one possible outcome could be death in the in-
terventional laboratory. After the resident left
the room, the child burst into tears, terrified
that he was going to die during the procedure.
It is imperative that all physicians interacting
with patients and families manifest a high de-
gree of sensitivity to their needs and vulnerabili-
ties. Radiologic tests and procedures are routine
for the radiologist, but they are usually new ex-
periences for patients and families and may pro-
voke a considerable degree of anxiety. Patients
often regard imaging examinations as potential
threats, insofar as they may reveal life-threaten-
ing diseases or injuries. Moreover, providing
patients with the information they need to give
informed consent brings to their attention addi-
tional risks of the procedures themselves. Physi-
cians can not simply neglect to mention the
41

unpleasant aspects of imaging, nor should they
sugar coat the risks in an effort to make things
easier for patients. On the other hand, such dis-
cussions can be handled in a gentle and com-
passionate way, and residents should endeavor
to interact with families with the same degree of
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sensitivity they would hope other physicians
would show their family members.
Courtesy
A busy attending radiologist and a resident
entered a patient examination room. Without a
word to the patient, they began to discuss the
patients condition and the appropriate tech-
nique for the examination. A minute later, they
both left the room, without ever saying hello to
her or introducing themselves. The patient
later reported that she wasnt sure they realized
that she had been in the room.
Patients are human beings too, and deserve to
be treated with an appropriate level of respect
and civility. It can be extremely disconcerting
and even humiliating to be talked to or about
without having first been introduced. The health
care enterprise is a complex one, especially from
the patients point of view, and patients may
come into contact with a bewildering variety of
health care workers during a single visit. A phy-
sician would never start an examination on a pa-
tient without first verifying the patients identity,
and patients have the same interest in knowing
who is caring for them. No matter how pressed
for time or overworked residents may be, even
forgiving patients are likely to perceive the resi-
dents as rude if they fail to introduce themselves.
Compassion
During a prolonged interventional procedure
performed under local anesthesia, the radiolo-
gists present discussed the similarities and differ-
ences between this patients condition and others
they had seen in the recent past. In part because
they never took time to explain to the patient
what they were doing or why, the patient later
complained that the experience left her feeling
like a piece of meat under a microscope.
Patients need to know that those caring for
them view them not merely as an assemblage of
organs or tissues, but as persons. This principle is
succinctly embodied in the comment of another
patient, who complained, I am a human being,
not a laboratory rat. Because the radiologists
expertise is based so thoroughly on images, re-
stricting the professional gaze to the anatomic
interior of the patient is an ever-present occupa-
tional liability. Yet from the patients point of
view, what the radiologist says is every bit as sig-
nificant as what the radiologist does. Radiolo-
gists need not take time out to give a lecture to
42
Gunderman
each patient, but nearly every patient encounter
is an important opportunity for education. Tak-
ing a minute or two to educate patients relieves a
good bit of their anxiety about the unknown.
Moreover, administering even minidoses of
teaching automatically invites the physician to
look at the health care encounter from the pa-
tients point of view (Does he or she understand
what I am doing and saying?), and gives the pa-
tient the sense of being treated as a person.
Appropriateness
Because of time constraints, a team of medi-
cal students came into the radiology department
to interview a father awaiting the completion of
his sons imaging examination. He later com-
plained, They were rude and asked the most ri-
diculous questions they could think of: whether
I am married to the childs mother, and whether
I have ever been arrested for child abuse. For
Gods sake, my son had a heart murmur picked
up at a routine check-up.
No template for the patientphysician en-
counter works well in all cases. Radiologists
must be attuned to the situation at hand and
adapt their approach accordingly. Even a single
inappropriate comment or question can seri-
ously undermine the relationship between a pa-
tient and a physician. Everything the radiologist
says to the patient is an opportunity to assess the
patients response and to adapt the discussion
accordingly, not simply a one-way transfer of
information. A key to effective communication
is good listening, including the ability to tune in
to nonverbal clues to the patients state of mind.
Honesty
During an imaging procedure, the radiology
nurse recommended that the resident use a par-
ticular piece of equipment. The resident in-
formed the nurse that her suggestion was
inappropriate. Later, when the attending radiol-
ogist entered to room to observe, he asked the
resident why he hadnt used that piece of equip-
ment. To the patients surprise, the resident took
no responsibility and instead blamed the nurse,
who had since left the room.
Few things are more corrosive to the trust on
which good patientphysician relationships de-
pend than dishonesty. Even apparently innocu-
ous instances of deception, the white lies a
physician might be tempted to tell in order to
provide reassurance to a patient, ultimately do
more harm than good by undermining trust [8].
Because patients need to be able to entrust phy-
sicians with their lives, physicians have a duty
to deal honestly with patients at all times. Pa-
tients need to know that they can confide in their
doctor, that their doctor is operating not from
pecuniary self-interest but out of a commitment
to their welfare, and that their doctor will be
there for them in times of need. When a patient
perceives that a physician has acted dishonestly,
word of mouth can damage the regard of many
friends and family members for the whole pro-
fession of medicine. The career of every physi-
cian has been enriched by the high standard of
conduct observed by professional forebears,
and it is incumbent on each physician to pre-
serve that trust for generations of physicians yet
to come. If something unfortunate has hap-
pened, it is better to acknowledge and express
regret about it than to attempt to cover it up.
Openness
A patient sat silently as two radiologists
discussed his case. After they left the room,
the patient commented, They never let me
in on what they were thinking. I would have
liked to know why they were saying all those
things, but instead I just felt like an idiot.
Patients should be regarded not as passive re-
cipients of medical ministrations, but as active
participants in their own care. Keeping the pa-
tient in the dark merely breeds uncertainty
and anxiety, as well as a sense of impotence that
is antithetical to a strong patientphysician alli-
ance. By getting patients actively involved in
their own care, physicians can improve both the
technical outcomes of care, through improved
patient compliance, and patients overall satis-
faction with the care they have received [9].
Moreover, keeping patients informed and in-
volved bespeaks a high level of physician re-
spect that helps to preserve and promote
patients sense of their own vigor and dignity.
Many of the procedures through which we put
patients can seem awkward and even dehuman-
izing, but explanations of what will happen and
why go a long way toward putting them at ease.
One of the best ways to make the experience
less discomfiting is to give patients opportuni-
ties to pose questions and take the time to an-
swer them appropriately. Many experiences in
the health care arena are so new that patients
may have difficulty formulating questions. In
such cases, it can be helpful for the physician to
offer, Some of the patients undergoing this
procedure wonder about. Such openness
helps patients feel that the radiologist under-
stands where they are and cares enough to help
them understand what is going on.
Practical Tips
These traits of effective communicators pro-
vide a theoretical underpinning for the develop-
ment of daily habits of effective communication.
However, the translation of theory into practice
AJR:177, July 2001

is not always a straightforward matter. To show
how these traits manifest themselves practically
in interactions between radiologists and patients,
I list 10 simple habits of communication that all
physicians can make use of in the first few min-
utes of every patient encounter. It is important
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that radiologists not view the first minute or two
of a patient encounter as a mere formality, an es-
sentially meaningless exchange of pleasantries,
but that they treat it as a crucial stage in building
a healthy patientphysician relationship.
Introduce yourself, shake hands with the pa-
tient and every family member or friend in the
room, and find out their names and relation-
ship. You do not want to mistakenly refer to the
patients mother as grandma during the ex-
amination.
Whenever addressing the patient and fam-
ily members, refer to them by name, generally
using Mr., Mrs., or Ms. Make sure you have
understood everyones name correctly; if nec-
essary, ask them to spell it.
Make eye contact with the person to whom
you are speaking. It is disconcerting to be
spoken to by someone who never looks you
in the eye, because it creates the impression
that they are avoiding something.
Touch the patient. No words can substitute.
Find out routinely how long the patient has
been waiting, and acknowledge it. When the
wait has been especially long, consider offer-
ing some explanation. It is possible to express
regret without accepting unwarranted blame.
Convey an understanding of the patients his-
tory. Such a demonstration provides reassurance
that the radiologist has done his homework,
and gives the patient a chance to expand or clar-
ify any important points.
Briefly explain any tests or procedures in
language that the patient and family can un-
derstand. A key part of any explanation is the
rationale, why the examination is being per-
formed in the first place.
AJR:177, July 2001
Teaching Patient Communication
Ask if the patient has any questions. Take
time to answer them, including, when appro-
priate, the admission, We dont know.
Listen, giving the patient your undivided at-
tention. It is acceptable to jot down notes as the
patient talks, but those notes should pertain to
what the patient is actually saying.
Look for opportunities to express respect
and admiration. Telling patients and families
that they are doing a good job frequently
means more to them than physicians would
ever suppose and enhances their ability to cope
with bad news, should the need arise.
Conclusion
Having considered what radiology residents
need to know about effective patient commu-
nication, how can we teach such skills? One
starting point is to make use of the vignettes
described, asking a group of residents to dis-
cuss opportunities to improve the quality of
communication in each case. In the course of
critiquing instances of poor communication,
residents become more attentive to their own
approaches. Second, staff radiologists should
make an effort to observe residents interac-
tions with patients and to provide structured,
constructive feedback. Communication de-
serves every bit as much one-on-one attention
as differential diagnosis and catheter tech-
nique. Finally, programs can provide addi-
tional resources for effective communication,
including information on verbal, nonverbal,
and image-mediated approaches as well as
tools for assessing patients level of under-
standing, conversing with patients who speak a
different language, and interacting with dis-
abled patients.
In discussing useful techniques of communi-
cation, the teaching physician should stress that
high-quality patientphysician interaction is not
merely a tool to be used for some other end. Ra-
diology residents must not be left with the im-
pression that the techniques of effective
communication deserve attention merely be-
cause they provide a means of manipulating pa-
tients to achieve more important goals, such as
higher customer satisfaction ratings or reduced
medicallegal liability. Rather, effective com-
munication and the enrichment of the pa-
tientphysician relationship are worthy ends
in themselves and deserve to be pursued for
their own sake, regardless what other benefits
they produce. They lie at the core of what it
means to be a good doctor, something to which
all good radiologists intrinsically aspire.
References
1. Hattery RR. The presidents message. ABR Ex-
aminer 2000;5:13
2. Brody DS, Miller SM, Lerman CE, et al. The rela-
tionship between patients satisfaction with their
physicians and perception about intervention they
devised and received. Med Care 1989;27:10271035
3. Greenfield S, Kaplan S, Ware JE. Expanding pa-
tient involvement in care: effects on patient out-
comes. Ann Intern Med 1985;102:520528
4. Stewart MA. Effective physician-patient commu-
nication and health outcomes: a review. Can Med
Assoc J 1995;152:14231433
5. Levinson W, Roter DL, Mullooly J, Dull VT,
Frankel RM. Physician-patient communication:
the relationship with malpractice claims among
primary care physicians and surgeons. JAMA
1997;277:553559
6. Beckman HB, Markakis KM, Suchman AL,
Frankel RM. The doctor-patient relationship and
malpractice: lessons from plaintiff depositions.
Arch Intern Med 1994;154:13651370
7. Chuck JM, Nesbitt TS, Kwan J, Kam SM. Is being
a doctor still fun? West J Med 1993;159:665669
8. Thom DH, Ribisl KM, Stewart AL, Luke DA. Fur-
ther validation and reliability testing of the trust in
physicians scale. Med Care 1999;37:510517
9. Safran DG, Taira DA, Rogers WH, et al. Linking
primary care performance to outcomes of care. J
Family Practice 1998;47:213220
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