Following part one of RTW Matters' interview with Dr Hari Dhir, this second part forms the last half of his insightful information on doctor-patient communication. American Dr Dhir is Medical Director at Concentra Health Services and Adjunct Associate Clinical Professor of Occupational and Environmental Medicine.

How can we assess when a medical practitioner is a poor communicator?

Communication skills can be assessed indirectly. A medical practitioner who has good communication skills will have increased patient satisfaction, reduced malpractice litigation, fewer clinical visits and improved health outcomes.

In research, analysis of the doctor-patient relationship is done using Interaction Analysis Systems (IASs) which are instruments that identify, quantify and categorise the salient features of communication. IASs are specific for certain encounters, use different observational strategies, have a specific focus and assess verbal or non-verbal behaviour, or both.

There are two types of IASs. They reflect the patient's need for care and cure when visiting the doctor. The to types are:

• 1) Cure systems, which capture task focused behaviour, and
• 2) Care systems, which measure affective behaviour.

How should an employer seek out for their employee a good, communicative medical practitioner? 

Any medical practitioner with high patient satisfaction and good clinical outcomes must have good communication skills. Good doctors will also have impeccable diagnostic and treating skills. A doctor with good communication skills will be a good listener. Empathy – the ability to take another's point of view and to project understanding of another's experience – is important in psychotherapy and may be important in the medical consult as well.

In a study published in the British Medical Journal it was stated that physicians interrupt patients within 18 seconds of them discussing the presenting complaint. The research group conducted 335 interviews. It found that the mean time before interruption was 92 seconds and that 258 (of the 335) individuals spoke for less than two minutes. Only seven patients spoke for five minutes or more and all the information disclosed by the patients during this uninterrupted time was clinically relevant.

This reminds me one of my patients who stepped on a nail. On the day of the injury I evaluated him. The x-rays of his foot were normal so the wound on his foot was cleaned, and he was given a tetanus shot and prescribed oral antibiotics. He followed up two days later and his symptoms had worsened.
His foot was now swollen and red. I had told him that it was very important that he see a foot surgeon because he may have a foreign body in his foot which did not show up on x-ray. He told me he was unable to see a surgeon, but I told him he must as soon as possible. He kept on saying he could not go and I kept on telling him that he must.

I realised I was getting nowhere fast, so I decided to stop and listen to the patient and let him talk uninterrupted. During this time I consciously noted non-verbal cues and increased the rapport with him. He talked uninterrupted for one to two minutes and during that time I gleaned more information than I had done in the previous 10 minutes of the consultation.

The patient explained that he had no money or transport so he was unable to get the antibiotics I had prescribed, and as he had no transport he was unable to go to the foot surgeon. After this I explained that the infection could worsen and if that happened he may need more extensive and drastic treatment. After he felt that I had listened to him, he understood that it was in his best interest to follow up with the surgeon, which he did. The surgeon removed a small fragment of his shoe which did not show up on the x-ray from deep inside of his foot.

Later the patient thanked me for my help. Had he not gone to the surgeon the outcome of this case could have been disastrous.

How can an employer benefit from their employee having a medical practitioner with good communication skills?

The employer can benefit with a healthier workforce, fewer clinical visits, fewer days off work or on light duty with reduced productivity, improved health outcomes with improved emotional health, reduced medical costs, reduced doctor shopping, fewer worker's compensation complaints and more rapid recovery for their employees.

In fact, with good communication everyone benefits. The patient benefits with better clinical outcomes and improved health. The physician benefits because the patient compliance is increased, and there are fewer complaints and malpractice litigation. The employer benefits because of reduced medical costs, fewer days off work or on light duty and more rapid recovery for their employees.