Comportment and Communication Score

In 2014, there were more than 40,000 hospitalists in the United States, and approximately 20% were employed by academic medical centers.[1] Hospitalist physicians groups are committed to delivering excellent patient care. However, the published literature is limited with respect to defining optimal care in hospital medicine.

Patient satisfaction surveys, such as Press Ganey (PG)[2] and Hospital Consumer Assessment of Healthcare Providers and Systems,[3] are being used to assess patients' contentment with the quality of care they receive while hospitalized. The Society of Hospital Medicine, the largest professional medical society representing hospitalists, encourages the use of patient satisfaction surveys to measure hospitalist providers' quality of patient care.[4] There are, however, several problems with the current methods. First, the attribution to specific providers is questionable. Second, recall about the provider by the patients may be poor because surveys are sent to patients days after they return home. Third, the patients' recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time. Thus, a tool that is able to provide feedback at the encounter level should be more helpful than a tool that offers assessment at the level of the admission, particularly when it can be also delivered immediately after the data are collected.

Comportment has been used to describe both the way a person behaves and also the way she carries herself (ie, her general manner).[5] Excellent comportment and communication can serve as the foundation for delivering patient‐centered care.[6, 7, 8] Patient centeredness has been shown to improve the patient experience and clinical outcomes, including compliance with therapeutic plans.[9, 10, 11] Respectful behavior, etiquette‐based medicine, and effective communication also lay the foundation upon which the therapeutic alliance between a doctor and patient can be built.

The goal of this study was to establish a metric that could comprehensively assess a hospitalist provider's comportment and communication skills during an encounter with a hospitalized patient.

METHODS

RESULTS

The average clinical experience of the 26 hospitalist physicians studied was 6 years (Table 1). Their mean age was 38 years, 13 (50%) were female, and 16 (62%) were of nonwhite race. Fourteen hospitalists (54%) worked at 1 of the nonacademic hospitals. In terms of clinical workload, most physicians (n = 17, 65%) devoted more than 70% of their time working in direct patient care. Mean time spent observing each physician was 280 minutes. During this time, the 26 physicians were observed for 181 separate clinical encounters; 54% of these patients were new encounters, patients who were not previously known to the physician. The average time each physician spent in a patient room was 10.8 minutes. Mean number of observed patient encounters per hospitalist was 7.

The distribution of HMCCOT scores was not statistically significantly different when analyzed by age, gender, race, amount of clinical experience, clinical workload of the hospitalist, hospital, time spent observing the hospitalist (all P > 0.05). The distribution of HMCCOT scores was statistically different in new patient encounters compared to follow‐ups (68.1% vs 39.7%, P 0.001). Encounters with patients that generated HMCCOT scores above versus below the mean were longer (13 minutes vs 8.7 minutes, P 0.001).

The mean HMCCOT score was 61 (standard deviation [SD] = 10.6), and it was normally distributed (Figure 1). Table 2 shows the data for the 23 behaviors that were objectively assessed as part of the HMCCOT for the 181 patient encounters. The most frequently observed behaviors were physicians washing hands after leaving the patient's room in 170 (94%) of the encounters and smiling (83%). The behaviors that were observed with the least regularity were using an empathic statement (26% of encounters), and employing teach‐back (13% of encounters). A common method of demonstrating interest in the patient as a person, seen in 41% of encounters, involved physicians asking about patients' personal histories and their interests.

Figure 1

The average composite PG scores for the physician sample was 38.95 (SD=39.64). A moderate correlation was found between the HMCCOT score and PG score (adjusted Pearson correlation: 0.45, P = 0.047).

DISCUSSION

In this study, we followed 26 hospitalist physicians during routine clinical care, and we focused intently on their communication and their comportment with patients at the bedside. Even among clinically respected hospitalists, the results reveal that there is wide variability in comportment and communication practices and behaviors at the bedside. The physicians' HMCCOT scores were associated with their PG scores. These findings suggest that improved bedside communication and comportment with patients might translate into enhanced patient satisfaction.

This is the first study that honed in on hospitalist communication and comportment. With validity evidence established for the HMCCOT, some may elect to more explicitly perform these behaviors themselves, and others may wish to watch other hospitalists to give them feedback that is tied to specific behaviors. Beginning with the basics, the hospitalists we studied introduced themselves to their patients at the initial encounter 78% of the time, less frequently than is done by primary care clinicians (89%) but more consistently than do emergency department providers (64%).[7] Other variables that stood out in the HMCCOT was that teach‐back was employed in only 13% of the encounters. Previous studies have shown that teach‐back corroborates patient comprehension and can be used to engage patients (and caregivers) in realistic goal setting and optimal health service utilization.[14] Further, patients who clearly understand their postdischarge plan are 30% less likely to be readmitted or visit the emergency department.[14] The data for our group have helped us to see areas of strengths, such as hand washing, where we are above compliance rates across hospitals in the United States,[15] as well as those matters that represent opportunities for improvement such as connecting more deeply with our patients.

Tackett et al. have looked at encounter length and its association with performance of etiquette‐based medicine behaviors.[7] Similar to their study, we found a positive correlation between spending more time with patients and higher HMCCOT scores. We also found that HMCCOT scores were higher when providers were caring for new patients. Patients' complaints about doctors often relate to feeling rushed, that their physicians did not listen to them, or that information was not conveyed in a clear manner.[16] Such challenges in physicianpatient communication are ubiquitous across clinical settings.[16] When successfully achieved, patient‐centered communication has been associated with improved clinical outcomes, including adherence to recommended treatment and better self‐management of chronic disease.[17, 18, 19, 20, 21, 22, 23, 24, 25, 26] Many of the components of the HMCCOT described in this article are at the heart of patient‐centered care.

Several limitations of the study should be considered. First, physicians may have behaved differently while they were being observed, which is known as the Hawthorne effect. We observed them for many hours and across multiple patient encounters, and the physicians were not aware of the specific types of data that we were collecting. These factors may have limited the biases along such lines. Second, there may be elements of optimal comportment and communication that were not captured by the HMCCOT. Hopefully, there are not big gaps, as we used multiple methods and an iterative process in the refinement of the HMCCOT metric. Third, one investigator did all of the observing, and it is possible that he might have missed certain behaviors. Through extensive pilot testing and comparisons with other raters, the observer became very skilled and facile with such data collection and the tool. Fourth, we did not survey the same patients that were cared for to compare their perspectives to the HMCCOT scores following the clinical encounters. For patient perspectives, we relied only on PG scores. Fifth, quality of care is a broad and multidimensional construct. The HMCCOT focuses exclusively on hospitalists' comportment and communication at the bedside; therefore, it does not comprehensively assess care quality. Sixth, with our goal to optimally validate the HMCCOT, we tested it on the top tier of hospitalists within each group. We may have observed different results had we randomly selected hospitalists from each hospital or had we conducted the study at hospitals in other geographic regions. Finally, all of the doctors observed worked at hospitals in the Mid‐Atlantic region. However, these five distinct hospitals each have their own cultures, and they are led by different administrators. We purposively chose to sample both academic as well as community settings.

In conclusion, this study reports on the development of a comportment and communication tool that was established and validated by following clinically excellent hospitalists at the bedside. Future studies are necessary to determine whether hospitalists of all levels of experience and clinical skill can improve when given data and feedback using the HMCCOT. Larger studies will then be needed to assess whether enhancing comportment and communication can truly improve patient satisfaction and clinical outcomes in the hospital.

Disclosures: Dr. Wright is a Miller‐Coulson Family Scholar and is supported through the Johns Hopkins Center for Innovative Medicine. Susrutha Kotwal, MD, and Waseem Khaliq, MD, contributed equally to this work. The authors report no conflicts of interest.

In 2014, there were more than 40,000 hospitalists in the United States, and approximately 20% were employed by academic medical centers.[1] Hospitalist physicians groups are committed to delivering excellent patient care. However, the published literature is limited with respect to defining optimal care in hospital medicine.

Patient satisfaction surveys, such as Press Ganey (PG)[2] and Hospital Consumer Assessment of Healthcare Providers and Systems,[3] are being used to assess patients' contentment with the quality of care they receive while hospitalized. The Society of Hospital Medicine, the largest professional medical society representing hospitalists, encourages the use of patient satisfaction surveys to measure hospitalist providers' quality of patient care.[4] There are, however, several problems with the current methods. First, the attribution to specific providers is questionable. Second, recall about the provider by the patients may be poor because surveys are sent to patients days after they return home. Third, the patients' recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time. Thus, a tool that is able to provide feedback at the encounter level should be more helpful than a tool that offers assessment at the level of the admission, particularly when it can be also delivered immediately after the data are collected.

Comportment has been used to describe both the way a person behaves and also the way she carries herself (ie, her general manner).[5] Excellent comportment and communication can serve as the foundation for delivering patient‐centered care.[6, 7, 8] Patient centeredness has been shown to improve the patient experience and clinical outcomes, including compliance with therapeutic plans.[9, 10, 11] Respectful behavior, etiquette‐based medicine, and effective communication also lay the foundation upon which the therapeutic alliance between a doctor and patient can be built.

The goal of this study was to establish a metric that could comprehensively assess a hospitalist provider's comportment and communication skills during an encounter with a hospitalized patient.

METHODS

RESULTS

The average clinical experience of the 26 hospitalist physicians studied was 6 years (Table 1). Their mean age was 38 years, 13 (50%) were female, and 16 (62%) were of nonwhite race. Fourteen hospitalists (54%) worked at 1 of the nonacademic hospitals. In terms of clinical workload, most physicians (n = 17, 65%) devoted more than 70% of their time working in direct patient care. Mean time spent observing each physician was 280 minutes. During this time, the 26 physicians were observed for 181 separate clinical encounters; 54% of these patients were new encounters, patients who were not previously known to the physician. The average time each physician spent in a patient room was 10.8 minutes. Mean number of observed patient encounters per hospitalist was 7.

The distribution of HMCCOT scores was not statistically significantly different when analyzed by age, gender, race, amount of clinical experience, clinical workload of the hospitalist, hospital, time spent observing the hospitalist (all P > 0.05). The distribution of HMCCOT scores was statistically different in new patient encounters compared to follow‐ups (68.1% vs 39.7%, P 0.001). Encounters with patients that generated HMCCOT scores above versus below the mean were longer (13 minutes vs 8.7 minutes, P 0.001).

The mean HMCCOT score was 61 (standard deviation [SD] = 10.6), and it was normally distributed (Figure 1). Table 2 shows the data for the 23 behaviors that were objectively assessed as part of the HMCCOT for the 181 patient encounters. The most frequently observed behaviors were physicians washing hands after leaving the patient's room in 170 (94%) of the encounters and smiling (83%). The behaviors that were observed with the least regularity were using an empathic statement (26% of encounters), and employing teach‐back (13% of encounters). A common method of demonstrating interest in the patient as a person, seen in 41% of encounters, involved physicians asking about patients' personal histories and their interests.

Figure 1

The average composite PG scores for the physician sample was 38.95 (SD=39.64). A moderate correlation was found between the HMCCOT score and PG score (adjusted Pearson correlation: 0.45, P = 0.047).

DISCUSSION

In this study, we followed 26 hospitalist physicians during routine clinical care, and we focused intently on their communication and their comportment with patients at the bedside. Even among clinically respected hospitalists, the results reveal that there is wide variability in comportment and communication practices and behaviors at the bedside. The physicians' HMCCOT scores were associated with their PG scores. These findings suggest that improved bedside communication and comportment with patients might translate into enhanced patient satisfaction.

This is the first study that honed in on hospitalist communication and comportment. With validity evidence established for the HMCCOT, some may elect to more explicitly perform these behaviors themselves, and others may wish to watch other hospitalists to give them feedback that is tied to specific behaviors. Beginning with the basics, the hospitalists we studied introduced themselves to their patients at the initial encounter 78% of the time, less frequently than is done by primary care clinicians (89%) but more consistently than do emergency department providers (64%).[7] Other variables that stood out in the HMCCOT was that teach‐back was employed in only 13% of the encounters. Previous studies have shown that teach‐back corroborates patient comprehension and can be used to engage patients (and caregivers) in realistic goal setting and optimal health service utilization.[14] Further, patients who clearly understand their postdischarge plan are 30% less likely to be readmitted or visit the emergency department.[14] The data for our group have helped us to see areas of strengths, such as hand washing, where we are above compliance rates across hospitals in the United States,[15] as well as those matters that represent opportunities for improvement such as connecting more deeply with our patients.

Tackett et al. have looked at encounter length and its association with performance of etiquette‐based medicine behaviors.[7] Similar to their study, we found a positive correlation between spending more time with patients and higher HMCCOT scores. We also found that HMCCOT scores were higher when providers were caring for new patients. Patients' complaints about doctors often relate to feeling rushed, that their physicians did not listen to them, or that information was not conveyed in a clear manner.[16] Such challenges in physicianpatient communication are ubiquitous across clinical settings.[16] When successfully achieved, patient‐centered communication has been associated with improved clinical outcomes, including adherence to recommended treatment and better self‐management of chronic disease.[17, 18, 19, 20, 21, 22, 23, 24, 25, 26] Many of the components of the HMCCOT described in this article are at the heart of patient‐centered care.

Several limitations of the study should be considered. First, physicians may have behaved differently while they were being observed, which is known as the Hawthorne effect. We observed them for many hours and across multiple patient encounters, and the physicians were not aware of the specific types of data that we were collecting. These factors may have limited the biases along such lines. Second, there may be elements of optimal comportment and communication that were not captured by the HMCCOT. Hopefully, there are not big gaps, as we used multiple methods and an iterative process in the refinement of the HMCCOT metric. Third, one investigator did all of the observing, and it is possible that he might have missed certain behaviors. Through extensive pilot testing and comparisons with other raters, the observer became very skilled and facile with such data collection and the tool. Fourth, we did not survey the same patients that were cared for to compare their perspectives to the HMCCOT scores following the clinical encounters. For patient perspectives, we relied only on PG scores. Fifth, quality of care is a broad and multidimensional construct. The HMCCOT focuses exclusively on hospitalists' comportment and communication at the bedside; therefore, it does not comprehensively assess care quality. Sixth, with our goal to optimally validate the HMCCOT, we tested it on the top tier of hospitalists within each group. We may have observed different results had we randomly selected hospitalists from each hospital or had we conducted the study at hospitals in other geographic regions. Finally, all of the doctors observed worked at hospitals in the Mid‐Atlantic region. However, these five distinct hospitals each have their own cultures, and they are led by different administrators. We purposively chose to sample both academic as well as community settings.

In conclusion, this study reports on the development of a comportment and communication tool that was established and validated by following clinically excellent hospitalists at the bedside. Future studies are necessary to determine whether hospitalists of all levels of experience and clinical skill can improve when given data and feedback using the HMCCOT. Larger studies will then be needed to assess whether enhancing comportment and communication can truly improve patient satisfaction and clinical outcomes in the hospital.

Disclosures: Dr. Wright is a Miller‐Coulson Family Scholar and is supported through the Johns Hopkins Center for Innovative Medicine. Susrutha Kotwal, MD, and Waseem Khaliq, MD, contributed equally to this work. The authors report no conflicts of interest.

In 2014, there were more than 40,000 hospitalists in the United States, and approximately 20% were employed by academic medical centers.[1] Hospitalist physicians groups are committed to delivering excellent patient care. However, the published literature is limited with respect to defining optimal care in hospital medicine.

Patient satisfaction surveys, such as Press Ganey (PG)[2] and Hospital Consumer Assessment of Healthcare Providers and Systems,[3] are being used to assess patients' contentment with the quality of care they receive while hospitalized. The Society of Hospital Medicine, the largest professional medical society representing hospitalists, encourages the use of patient satisfaction surveys to measure hospitalist providers' quality of patient care.[4] There are, however, several problems with the current methods. First, the attribution to specific providers is questionable. Second, recall about the provider by the patients may be poor because surveys are sent to patients days after they return home. Third, the patients' recovery and health outcomes are likely to influence their assessment of the doctor. Finally, feedback is known to be most valuable and transformative when it is specific and given in real time. Thus, a tool that is able to provide feedback at the encounter level should be more helpful than a tool that offers assessment at the level of the admission, particularly when it can be also delivered immediately after the data are collected.

Comportment has been used to describe both the way a person behaves and also the way she carries herself (ie, her general manner).[5] Excellent comportment and communication can serve as the foundation for delivering patient‐centered care.[6, 7, 8] Patient centeredness has been shown to improve the patient experience and clinical outcomes, including compliance with therapeutic plans.[9, 10, 11] Respectful behavior, etiquette‐based medicine, and effective communication also lay the foundation upon which the therapeutic alliance between a doctor and patient can be built.

The goal of this study was to establish a metric that could comprehensively assess a hospitalist provider's comportment and communication skills during an encounter with a hospitalized patient.

METHODS

RESULTS

The average clinical experience of the 26 hospitalist physicians studied was 6 years (Table 1). Their mean age was 38 years, 13 (50%) were female, and 16 (62%) were of nonwhite race. Fourteen hospitalists (54%) worked at 1 of the nonacademic hospitals. In terms of clinical workload, most physicians (n = 17, 65%) devoted more than 70% of their time working in direct patient care. Mean time spent observing each physician was 280 minutes. During this time, the 26 physicians were observed for 181 separate clinical encounters; 54% of these patients were new encounters, patients who were not previously known to the physician. The average time each physician spent in a patient room was 10.8 minutes. Mean number of observed patient encounters per hospitalist was 7.

The distribution of HMCCOT scores was not statistically significantly different when analyzed by age, gender, race, amount of clinical experience, clinical workload of the hospitalist, hospital, time spent observing the hospitalist (all P > 0.05). The distribution of HMCCOT scores was statistically different in new patient encounters compared to follow‐ups (68.1% vs 39.7%, P 0.001). Encounters with patients that generated HMCCOT scores above versus below the mean were longer (13 minutes vs 8.7 minutes, P 0.001).

The mean HMCCOT score was 61 (standard deviation [SD] = 10.6), and it was normally distributed (Figure 1). Table 2 shows the data for the 23 behaviors that were objectively assessed as part of the HMCCOT for the 181 patient encounters. The most frequently observed behaviors were physicians washing hands after leaving the patient's room in 170 (94%) of the encounters and smiling (83%). The behaviors that were observed with the least regularity were using an empathic statement (26% of encounters), and employing teach‐back (13% of encounters). A common method of demonstrating interest in the patient as a person, seen in 41% of encounters, involved physicians asking about patients' personal histories and their interests.

Figure 1

The average composite PG scores for the physician sample was 38.95 (SD=39.64). A moderate correlation was found between the HMCCOT score and PG score (adjusted Pearson correlation: 0.45, P = 0.047).

DISCUSSION

In this study, we followed 26 hospitalist physicians during routine clinical care, and we focused intently on their communication and their comportment with patients at the bedside. Even among clinically respected hospitalists, the results reveal that there is wide variability in comportment and communication practices and behaviors at the bedside. The physicians' HMCCOT scores were associated with their PG scores. These findings suggest that improved bedside communication and comportment with patients might translate into enhanced patient satisfaction.

This is the first study that honed in on hospitalist communication and comportment. With validity evidence established for the HMCCOT, some may elect to more explicitly perform these behaviors themselves, and others may wish to watch other hospitalists to give them feedback that is tied to specific behaviors. Beginning with the basics, the hospitalists we studied introduced themselves to their patients at the initial encounter 78% of the time, less frequently than is done by primary care clinicians (89%) but more consistently than do emergency department providers (64%).[7] Other variables that stood out in the HMCCOT was that teach‐back was employed in only 13% of the encounters. Previous studies have shown that teach‐back corroborates patient comprehension and can be used to engage patients (and caregivers) in realistic goal setting and optimal health service utilization.[14] Further, patients who clearly understand their postdischarge plan are 30% less likely to be readmitted or visit the emergency department.[14] The data for our group have helped us to see areas of strengths, such as hand washing, where we are above compliance rates across hospitals in the United States,[15] as well as those matters that represent opportunities for improvement such as connecting more deeply with our patients.

Tackett et al. have looked at encounter length and its association with performance of etiquette‐based medicine behaviors.[7] Similar to their study, we found a positive correlation between spending more time with patients and higher HMCCOT scores. We also found that HMCCOT scores were higher when providers were caring for new patients. Patients' complaints about doctors often relate to feeling rushed, that their physicians did not listen to them, or that information was not conveyed in a clear manner.[16] Such challenges in physicianpatient communication are ubiquitous across clinical settings.[16] When successfully achieved, patient‐centered communication has been associated with improved clinical outcomes, including adherence to recommended treatment and better self‐management of chronic disease.[17, 18, 19, 20, 21, 22, 23, 24, 25, 26] Many of the components of the HMCCOT described in this article are at the heart of patient‐centered care.

Several limitations of the study should be considered. First, physicians may have behaved differently while they were being observed, which is known as the Hawthorne effect. We observed them for many hours and across multiple patient encounters, and the physicians were not aware of the specific types of data that we were collecting. These factors may have limited the biases along such lines. Second, there may be elements of optimal comportment and communication that were not captured by the HMCCOT. Hopefully, there are not big gaps, as we used multiple methods and an iterative process in the refinement of the HMCCOT metric. Third, one investigator did all of the observing, and it is possible that he might have missed certain behaviors. Through extensive pilot testing and comparisons with other raters, the observer became very skilled and facile with such data collection and the tool. Fourth, we did not survey the same patients that were cared for to compare their perspectives to the HMCCOT scores following the clinical encounters. For patient perspectives, we relied only on PG scores. Fifth, quality of care is a broad and multidimensional construct. The HMCCOT focuses exclusively on hospitalists' comportment and communication at the bedside; therefore, it does not comprehensively assess care quality. Sixth, with our goal to optimally validate the HMCCOT, we tested it on the top tier of hospitalists within each group. We may have observed different results had we randomly selected hospitalists from each hospital or had we conducted the study at hospitals in other geographic regions. Finally, all of the doctors observed worked at hospitals in the Mid‐Atlantic region. However, these five distinct hospitals each have their own cultures, and they are led by different administrators. We purposively chose to sample both academic as well as community settings.

In conclusion, this study reports on the development of a comportment and communication tool that was established and validated by following clinically excellent hospitalists at the bedside. Future studies are necessary to determine whether hospitalists of all levels of experience and clinical skill can improve when given data and feedback using the HMCCOT. Larger studies will then be needed to assess whether enhancing comportment and communication can truly improve patient satisfaction and clinical outcomes in the hospital.

Disclosures: Dr. Wright is a Miller‐Coulson Family Scholar and is supported through the Johns Hopkins Center for Innovative Medicine. Susrutha Kotwal, MD, and Waseem Khaliq, MD, contributed equally to this work. The authors report no conflicts of interest.