Wisconsin Medical Examining Board Newsletter

Several decades ago, I participated in a surgical externship, where I spent an entire summer at a hospital following a resident and scrubbing in on multiple cases with multiple attending physicians. It was one of the best learning experiences I had in my education.

I was particularly intrigued by something unrelated to the procedural interventions, laboratory work, and interpretations of imaging results. One surgeon had a larger than average number of complications in his case outcomes compared to his colleague. Yet he was beloved by his patients, whereas the colleague was subjected to complaints and even malpractice suits. While I did not understand why patients did not appreciate the skill of the latter surgeon, I was impressed by the patience that the first doctor exercised with his patients. I noticed that when he made his post-surgical rounds, he seemed to have an unlimited amount of time to spend with each patient. His colleague, on the other hand, had a somewhat more gruff and abbreviated style of communicating.

There is data to indicate that communication issues are a leading cause of complaints filed against physicians. One notable study, a ten-year review of complaints by the North Carolina Medical Board, found communication was the most prevalent reason for complaints against physicians, accounting for more than 20% of complaints filed (North Carolina Medical Board Medical Board Data Analysis, 2002-2012). Examples of poor communication included failure by the physician to consider the patient’s unique intellectual and cultural background, failure of the physician to maintain an appropriate level of professionalism when confronted by a difficult or contentious patient, lack of timely follow-up communication with patients about abnormal laboratory studies, and insufficiently conveying relevant details of the physician’s plan of care or treatment decisions. (As an aside, one the most difficult tasks in screening a complaint is to read 10,000-15,000 pages of documentation and not have any sense of what the physician’s case formulation was or where they were headed with respect to treatment.)

What can be described as “poor bedside manner” is a leading cause of complaints. These kinds of complaints include patients feeling rushed, being interrupted, experiencing poor eye contact, not being listened to, not having concerns addressed, being scolded about their adherence to treatment, perceiving the physician as flippant or condescending, and experiencing as jarring comments by the physician that the physician believes are innocuous statements. Especially pervasive is the interruption of patients when they are trying to speak. A Journal of General Internal Medicine article (8/6/2019) noted that the average length of time before a patient’s narrative was interrupted was 11 seconds. A Journal of the American Medical Association Network article (7/4/2107) noted 12 seconds on average before an interruption, and an article from the National Institutes of Health (9/8/2023) noted that 70% of physician consultants interrupted a patient’s opening remarks. In addition, doctors who listen less miss obtaining relevant and important information. This leads to more medical errors, such as misdiagnosis or failure to adequately treat.

Physicians should be alert to health system and employment factors that can impact their ability to communicate optimally. First, electronic record keeping demands and billing schedules can detract from the physician-patient relationship. It has been noted that when using electronic health records, physicians spend about a third of the time looking at the record instead of the patient. Second, physicians are less directly involved in scheduling appointments (and allocating face-to-face time) with patients. Similarly, wait time for appointments can adversely impact patient satisfaction. Third, there are clinical settings in which a physician will have limited interaction with a patient where non-physician practitioners may be the point person with the patient and involve the physician more by consultation or through a delegated, supervisory or collaborative relationship. These types of patient care models may require the physician to take more initiative to ensure they are communicating effectively with the patient and within the care team. Fourth, incomplete comprehension of privacy provisions (e.g., Health Insurance Portability and Accountability Act) can create misunderstandings and dissatisfaction. Lastly, patient satisfaction surveys produce useful evaluations but they may also provide an incomplete picture or miss the mark in other ways, so physicians should be aware of their value and drawbacks when deployed within their institutions.

Patients and their family members are the source of most complaints made to state medical boards. Every year the Wisconsin Medical Examining Board receives approximately 600 complaints regarding physician conduct in Wisconsin. About 40-50 complaints are reviewed monthly by screening panels, which are comprised of 2 physician Board members and one public Board member. On average, at least a third of these complaints are opened for further investigation. Based on a 2019 Federation of State Medical Boards (FSMB) commissioned survey, we expect that one in five Americans have had an interaction with a physician whom they believe was acting unethically, unprofessionally, or providing substandard care. Of this group, one in three will file some sort of complaint, and a third of those will file a complaint with a state medical board.

There are suggestions for improving communication. Maintaining professionalism in difficult situations is often a challenge, and it is necessary to carefully navigate and thoughtfully respond to the trying situations and stressors. Learning “teach back” skills can help. In patient encounters, important considerations include listening more (talking and interrupting less), pausing to allow for questions, minimizing screen time, showing empathy, avoiding the use of “jargon,” protecting privacy, ensuring informed consent is obtained, and avoiding the feeling of a time crunch. Sometimes explaining to a patient and, with permission, their family members and/or legally authorized representative(s) what is feasible within a health system may be helpful. Advocating for changes in one’s health care system to improve both the patient and physician experience when appropriate and when possible is also a worthy endeavor.

In addition, ensuring clarity in written communications is extremely important, especially when past records are part of a review. Documentation should be thorough and demonstrate that the physician has a plan of care and has used solid clinical reasoning.

In teaching students and residents, I have consistently instructed that patients expect their physician to be competent and they expect their physician to listen to them. For more than 20 years, the Accreditation Council for Graduate Medical Education (ACGME) has included interpersonal and communication skills as a core competency. Likewise, medical licensure examinations have built effective communication skills into their domains. With increased awareness of the importance of effective communication I find reason to be optimistic about improvements in physician-patient communication. Let’s hope more improvements will follow and lead us to better patient outcomes, fewer complaints, and a corresponding reduction in resources expended in responding to complaints.