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A practicing oncologist likely uses just about every medium to communicate. They talk on the phone, send e-mail messages, converse one-on-one, participate in meetings, and give verbal and written orders. And they communicate with many audiences—patients and their families, referring physicians, and office staff.
But are you communicating effectively? How do you handle differing or challenging perspectives? Are you hesitant to disagree with others, especially those in authority? Do you find meetings are a waste of time? What impression does your communication style make on the members of your group?
The starting place for effective communication is effective listening. “Active listening is listening with all of one's senses,” says physician communication expert Kenneth H. Cohn, MD, MBA, FACS. “It's listening with one's eyes as well as one's years. Only 8% of communication is related to content—the rest pertains to body language and tone of voice.” A practicing surgeon as well as a consultant, Cohn is the author of Better Communication for Better Care and Collaborate for Success!
Cohn suggests creating a setting in which “listening can be accommodating.” For example, don't have a conversation when one person is standing and one person is sitting—make sure your eyes are at the same level. Eliminate physical barriers, such as a desk, between you and the other party. Acknowledge the speaker with your own body language: lean forward slightly and maintain eye contact. Avoid crossing your arms, which conveys a guarded stance and may suggest arrogance, dislike, or disagreement.
When someone is speaking, put a premium on “being present.” Take a deep breath (or drink some water to keep from speaking) and create a mental and emotional connection between you and the speaker. “This is not a time for multitasking, but to devote all the time to that one person,” Cohn advises. “If you are thinking about the next thing you have to do or, worse, the next thing you plan to say, you aren't actively listening.”
Suspending judgment is also part of active listening, according to Cohn. Encourage the speaker to fully express herself or himself—free of interruption, criticism, or direction. Show your interest by inviting the speaker to say more with expressions such as “Can you tell me more about it?” or “I'd like to hear about that.”
Finally, reflect back to the speaker your understanding of what has been said, and invite elaboration and clarification. Responding is an integral part of active listening and is especially important in situations involving conflict.
In active listening, through both words and nonverbal behavior, you convey these messages to the speaker:
Effective communication requires paying attention to an entire process, not just the content of the message. When you are the messenger in this process, you should consider potential barriers at several stages that can keep your intended audience from receiving your message.
Be aware of how your own attitudes, emotions, knowledge, and credibility with the receiver might impede or alter whether and how your message is received. Be aware of your own body language when speaking. Consider the attitudes and knowledge of your intended audience as well. Diversity in age, sex, and ethnicity or race adds to the communication challenges, as do different training backgrounds.
Individuals from different cultures may assign very different meanings to facial expressions, use of space, and, especially, gestures. For example, in some Asian cultures women learn that it is disrespectful to look people in the eye and so they tend to have downcast eyes during a conversation. But in the United States, this body language could be misinterpreted as a lack of interest or a lack of attention.
Choose the right medium for the message you want to communicate. E-mail or phone call? Personal visit? Group discussion at a meeting? Notes in the margin or a typed review? Sometimes more than one medium is appropriate, such as when you give the patient written material to reinforce what you have said, or when you follow-up a telephone conversation with an e-mail beginning, “As we discussed.…”
For one-on-one communication, the setting and timing can be critical to communicating effectively. Is a chat in the corridor OK, or should this be a closed-door discussion? In your office or over lunch? Consider the mindset and milieu of the communication receiver. Defer giving complex information on someone's first day back from vacation or if you are aware of situations that may be anxiety-producing for that individual. Similarly, when calling someone on the phone, ask initially if this is a convenient time to talk. Offer to set a specific time to call back later.
Finally, organize content of the message you want to communicate. Make sure the information you are trying to convey is not too complex or lengthy for either the medium you are using or the audience. Use language appropriate for the audience. With patients, avoid medical jargon.
Many nonverbal cues such as laughing, gasping, shoulder shrugging, and scowling have meanings that are well understood in our culture. But the meaning of some of these other more subtle behaviors may not be as well known.1
Hand movements. Our hands are our most expressive body parts, conveying even more than our faces. In a conversation, moving your hand behind your head usually reflects negative thoughts, feelings, and moods. It may be a sign of uncertainty, conflict, disagreement, frustration, anger, or dislike. Leaning back and clasping both hands behind the neck is often a sign of dominance.
Blank face. Though theoretically expressionless, a blank face sends a strong do not disturb message and is a subtle sign to others to keep a distance. Moreover, many faces have naturally down turned lips and creases of frown lines, making an otherwise blank face appear angry or disapproving.
Smiling. Although a smile may show happiness, it is subject to conscious control. In the United States and other societies, for example, we are taught to smile whether or not we actually feel happy, such as in giving a courteous greeting.
Tilting the head back. Lifting the chin and looking down the nose are used throughout the world as nonverbal signs of superiority, arrogance, and disdain.
Parting the lips. Suddenly parting one's lips signals mild surprise, uncertainty, or unvoiced disagreement.
Lip compression. Pressing the lips together into a thin line may signal the onset of anger, dislike, grief, sadness, or uncertainty.
In oncology, as in most medical practices, much of the work is done by teams. Communication within a team calls for clarifying goals, structuring responsibilities, and giving and receiving credible feedback.
“Physicians in general are at a disadvantage because we haven't been trained in team communication,” says Cohn. He points out that when he was in business school, as much as 30% to 50% of a grade came from team projects. “But how much of my grade in medical school was from team projects? Zero.”
The lack of systematic education about how teams work is the biggest hurdle for physicians in building a team culture, according to Cohn. “We've learned team behaviors from our clinical mentors, who also had no formal team training. The styles we learn most in residency training are ‘command and control’ and the ‘pace setting approach,’ in which the leader doesn't specify what the expectations are, but just expects people to follow his or her example.”
Cohn says that both of those styles limit team cohesion. “Recognizing one's lack of training is the first step [in overcoming the hurdle], then understanding that one can learn these skills. Listening, showing sincere empathy, and being willing to experiment with new leadership styles, such as coaching and developing a shared vision for the future are key.”
Stated goals and team values. An effective team is one in which everyone works toward a common goal. This goal should be clearly articulated. In patient care, of course, the goal is the best patient outcomes. But a team approach is also highly effective in reaching other goals in a physician practice, such as decreasing patient waiting times, recruiting patients for a clinical trial, or developing a community education program. Every member of the team must be committed to the team's goal and objectives.
Effective teams have explicit and appropriate norms, such as when meetings will be held and keeping information confidential. Keep in mind that it takes time for teams to mature and develop a climate of trust and mutual respect. Groups do not progress from forming to performing without going through a storming phase in which team members negotiate assumptions and expectations for behavior.2
Clear individual expectations. All the team members must be clear about what is expected of them individually and accept their responsibility for achieving the goal. They should also understand the roles of others. Some expectations may relate to their regular job duties; others may be one-time assignments specific to the team goal. Leadership of the team may rotate on the basis of expertise.
Members must have resources available to accomplish their tasks, including time, education and equipment needed to reach the goal. Openly discuss what is required to get the job done and find solutions together as a team.
Empowerment. Everyone on the team should be empowered to work toward the goal in his or her own job, in addition to contributing ideas for the team as a whole. Physicians' instinct and training have geared them to solve problems and give orders—so they often try to have all the answers. But in an effective team, each team member feels ownership in the outcome and has a sense of shared accountability. Cohn notes, “You get a tremendous amount of energy and buy-in when you ask ‘What do you think?’”
Team members must trust each other with important tasks. This requires accepting others for who they are, being creative, and taking prudent risks. Invite team members to indicate areas in which they would like to take initiative. Empower them by giving them the freedom to exercise their own discretion.
Feedback. Providing feedback on performance is a basic tenet of motivation. For some goals, daily or weekly results are wanted, while for others, such as a report of the number of medical records converted to a new system or the average patient waiting times, a monthly report might be appropriate. Decide together as a team what outcomes should be reported and how often.
Positive reinforcement. Team members should encourage one another. Take the lead and set an example by encouraging others when they are down and praising them when they do well. Thank individuals for their contributions, both one on one and with the team as a whole. Celebrate milestones as a way to sustain team communication and cohesion.
E-mail has numerous features that make it a wonderful tool for communicating with a team: it is immediate; it is automatically time-stamped; and filing and organizing are easy. (E-mail with patients is a more complex topic and is not addressed herein.)
The e-mail subject line is an especially useful feature that is typically underused. Make it your best friend. Use it like a newspaper headline, to draw the reader in and convey your main point or alert the reader to a deadline. In the examples given below, the person receiving an e-mail headed “HCC” is likely to scroll past it—planning to read it on the weekend. The more helpful subject line alerts the reader to be prepared to discuss the topic at an upcoming meeting:
As with all written communication, the most important aspect to consider is the audience. Consider the knowledge and biases of the person/people you are e-mailing. Where will the reader be when he or she receives your message? How important is your message to the reader?
The purpose of writing is to engage the reader. You want the reader to do something, to know something, or to feel something. Write it in a way that helps the reader. Put the most important information—the purpose of the email—in the first paragraph.
Except among friends who know you well, stay away from sarcasm in e-mail messages. The receiver does not have the benefit of your tone of voice and body language to help interpret your communication. When delivering comments that are even slightly critical, it's better to communicate in person or in a phone call than to do so in an e-mail. Something you wrote with good intentions and an open mind or even with humor can be interpreted as nitpicky, negative, and destructive, and can be forwarded to others.
Because we use e-mail for its speed, it's easy to get in the habit of dashing off a message and hitting the “send” button. We count on the automatic spell-check (and you should have it turned on as your default option) to catch your errors. But spelling typos are the least of the problems in communicating effectively.
Take the time to read through your message. Is it clear? Is it organized? Is it concise? See if there is anything that could be misinterpreted or raises unanswered questions. The very speed with which we dash off e-mail messages makes e-mail the place in which we are most likely to communicate poorly.
Finally, don't forget to supply appropriate contact information, including phone numbers or alternative e-mail addresses, for responses or questions.
Conflict is inevitable in times of rapid change. Effective communication helps one avoid conflict and minimize its adverse consequences when it does occur. The next issue of Strategies for Career Success will cover conflict management.
A good meeting is one in which team goals are introduced or reinforced and solutions are generated. The first rule—meet in person only if it's the best format to accomplish what you want. You don't need a meeting just to report information. Here are tips for facilitating an effective meeting:
Don't meet just because it's scheduled. If there are no issues to discuss, don't hold the meeting just because it's Tuesday and that's when you always meet.
Use an agenda. Circulate a timed agenda beforehand and append useful background information. Participants should know what to expect. If it's a short meeting or quickly called, put the agenda on a flipchart or board before people arrive.
Structure input. Promote the team culture by making different individuals responsible for specific agenda items. Follow-up on previous task assignments as the first agenda item to hold group members accountable for the team's success.
Limit the meeting time. Use the timed agenda to stay on track. If the discussion goes off on a tangent, bring the group back to the objective of the topic at hand. If it becomes clear that a topic needs more time, delineate the issues and the involved parties and schedule a separate meeting.
Facilitate discussion. Be sure everyone's ideas are heard and that no one dominates the discussion. If two people seem to talk only to each other and not to the group as a whole, invite others to comment. If only two individuals need to pursue a topic, suggest that they continue to work on that topic outside the meeting.
Set ground rules up front. Keep meetings constructive, not a gripe session. Do not issue reprimands, and make it clear that the meeting is to be positive and intended for updates, analysis, problem solving, and decision making. Create an environment in which disagreement and offering alternative perspectives are acceptable. When individuals do offer opposing opinions, facilitate open discussion that focuses on issues and not personalities.
Circulate a meeting summary before the next meeting. Formal minutes are appropriate for some meetings. But in the very least, a brief summary of actions should be prepared. Include decisions reached and assignments made, with deadlines for follow-up at the next meeting.
Kenneth H. Cohn: Better Communication for Better Care: Mastering Physician-Administrator Collaboration. Chicago, IL, Health Administration Press, 2005, www.ache.org/pubs/redesign/productcatalog.cfm?pc=WWW1-2038
Kenneth H. Cohn: Collaborate for Success! Breakthrough Strategies for Engaging Physicians, Nurses, and Hospital Executives. Chicago, IL, Health Administration Press, 2006, www.ache.org/hap.cfm
Suzette Haden Elgin: Genderspeak: Men, Women, and the Gentle Art of Verbal Self-Defense. Hoboken, NJ, Wiley, 1993
Jon R. Katzenbach, Douglas K. Smith: The Wisdom of Teams: Creating the High Performance Organization. New York, NY, Harper Business, 1994
Sharon Lippincott: Meetings: Do's, Don'ts, and Donuts. Pittsburgh, PA, Lighthouse Point Press, 1994
Kenneth W. Thomas: Intrinsic Motivation at Work: Building Energy and Commitment. San Francisco, CA, Berrett-Koehler Publishers, 2000
Deciding About Practice Options—J Oncol Pract 2:187-190, 2006
The Interview: Make it Work for You—J Oncol Pract 2:252-254, 2006
Employment Contracts: What to Look for—J Oncol Pract 2:308-311, 2006
Principles and Tactics of Negotiation—J Oncol Pract 3:102-105, 2007
Professional Advisors: They're Worth It—J Oncol Pract 3:162-166, 2007
Building and Maintaining a Referral Base—J Oncol Pract 3:227-230, 2007
Malpractice Insurance: What You Need to Know—J Oncol Pract 3:274-277, 2007
Joining a Practice As a Shareholder—J Oncol Pract 3:41-44, 2007.