Dialogue: The Core Clinical Skill

The field of communications has advanced tremendously over the past 30 years. I am not speaking of satellite-enabled, worldwide transmission of images and words but of person-to-person communications-the methods humans deliberately use to affect each other's thoughts, feelings, and motivations. Politicians, business leaders, and advertisers have adopted the wisdom of this science to influence elections, increase productivity, and motivate us to buy products. Psychiatry roots its expertise in the science of interpersonal communication. Much psychiatric diagnosis and treatment occurs during the talk between psychiatrist and patient. The field of family practice has recognized the centrality of human communications by requiring accredited residencies to have a specific curriculum in behavioral and psychosocial medicine.

Many social scientists, some working alone, others working with clinician-teachers in the Society of General Internal Medicine, the American Academy on Physician and Patient, the Society of Teachers of Family Medicine, and the Association for Behavioral Sciences in Medical Education, have developed models of the dialogue between patients and physicians. They have studied medical encounters and clinical teaching exercises to define what constitutes effective and efficient physician–patient communications. These groups have advanced the idea that what physicians do, say, feel, and believe when interacting with patients affects the outcome of care. For example, Levinson and Roter [1] analyzed pre- and post-course audiotapes of interviews from two groups of physicians: one that attended a 2.5-day course and one that attended a half-day seminar. Physicians who took the long course asked more open-ended questions, solicited more patient opinions, and gave more biomedical information than the other group. More impressive is that the patients of physicians who took the long course disclosed more biomedical and psychosocial information and that the interviews with these patients had less negative affect for both patient and physician.

In a study of how physicians communicate “understanding,” …