Dr Graham Billingham outlines the impact of ‘soft skills’ on the prevention of medical malpractice
The practice of medicine has long been held as an esteemed profession comprised of highly intelligent, educated, and skilled individuals. Historically, physicians have been viewed as authoritative figures whose intellectual knowledge and technical expertise are at the heart of their ability to successfully diagnose and treat patients.
In more recent years, however, a shift has occurred that aims to place patients at the centre of the care experience. Patient satisfaction, patient engagement, and collaborative care have, in many ways, shifted the focus solely from clinicians’ knowledge and technical acumen to a broader range of desirable skills – including many ‘soft skills’.
Soft skills are personal traits or attributes that, per the Oxford Dictionary, “enable someone to interact effectively and harmoniously with other people.” Many individuals and groups have advocated for changing the term soft skills to behavioural skills, core skills, power skills, human skills, social skills, or similar to avoid the notion that these skills are easy to acquire and use.
In medicine and other professions, soft skills allow individuals to communicate effectively, build relationships, solve problems, and maintain professionalism.
“Soft skills are considered to be a complement to hard skills, which refer to a person’s knowledge and occupational skills. Sociologists may use the term soft skills to describe a person’s emotional intelligence quotient as opposed to intelligence quotient.”
The number of soft skills is vast, and examples include empathy, humility, active listening, communication, teamwork, critical thinking, honesty, integrity, leadership, and respect. Although some of these skills may develop naturally, many times they must be learned and practised. Medical education and training, however, have not always provided these opportunities. The entrance process for medical schools has often focused on selecting students who are top academic achievers, excel at exams, and are assertive and competitive. Following medical school, residency training is rigorous with long hours spent on learning the hard skills necessary for technical excellence and medical decision-making.
Over the past 10-to-15 years, these processes have evolved, with the goal of developing clinicians who have both the necessary hard skills and soft skills to drive patient-centred care. For example, in Ireland, the HPAT entrance exam was introduced for prospective medical students in 2009 to assess certain non-academic qualities, which were not adequately assessed in the Leaving Cert. The HPAT exam measures a candidate’s problem solving, interpersonal understanding and analytical skills, which are deemed necessary for the medical profession to carry out their duties. Additionally, interpersonal skills, communication, and professionalism are now firmly incorporated into the curriculum and core competencies for both undergraduate and specialist training. Javelin Learning Solutions, an industrial-organisational psychology firm in the United States, notes that:
“Data show that strong medical knowledge and good clinical ability can be augmented by superior interpersonal skills. Doctors and healthcare leaders are actively working to improve the levels of soft skill proficiency in medicine everywhere. A path to better outcomes and patient experience can be traced by how much attention physicians pay to cultivating these ‘soft’ yet crucial skills.”
We now generally understand and accept that soft skills play an important role in patient engagement and satisfaction. Less is known about the direct relationship between these skills and patient outcomes and malpractice risk – likely because they are more subjective and difficult to quantify than other risk factors, such as technical skill failures. However, when looking at 10 years of medical malpractice claims data, communication issues are a critical contributing factor in 44 per cent of all cases. Communication encompasses, or is related to, many of the soft skills that are essential to medical care, such as active listening, teamwork, conflict management and resolution, dignity, building relationships, cultural competence, problem solving, and more.
Inadequate or poor communication can occur among various members of the care team or between clinicians and patients. In either scenario, communication breakdowns can lead to errors and patient harm. Therefore, having well-defined communication protocols for care coordination and care transitions, as well as strategies for building strong doctor–patient relationships and addressing patient communication barriers (eg, poor health literacy and cultural differences), are essential risk management and patient safety actions in all healthcare settings.
Of equal importance with communication is attitude, which often is reflected in behaviour. A negative attitude can affect how a clinician verbally and nonverbally interacts with other members of the care team and with patients. For example, if a physician is hostile, rude, or dismissive to colleagues, they might hesitate to raise safety concerns, and thereby potentially increasing the risk of adverse outcomes. Likewise, if a patient perceives a physician as paternalistic, patronising, condescending, or uncaring, those perceptions can set the tone for the doctor-patient relationship and may affect various aspects of the care process, such as information gathering, examination, treatment planning, patient consent to treatment, and patient adherence to treatment regimens.
Addressing attitude and associated behavioural issues requires healthcare organisations to have and enforce robust policies related to professionalism, code of conduct, anti-harassment, and culture of safety. For example, the Risk Management Foundation of the Harvard Medical Institution devised a surgery code of excellence consisting of 11 domains that define expectations related to service, respect, teamwork, openness, humility, and more. A 2019 study used 360-degree reviews to assess surgeons according to Harvard’s surgery code of excellence and concluded that negative physician behaviours are associated with increased malpractice risk. Further, another 2019 study found that the patients of surgeons who had more reports of unprofessional behaviour had a significantly increased risk of surgical and medical complications.
On an individual level, physicians also should consider how patients perceive their demeanor and communication style. Reflective practice and situational awareness can help clinicians understand the impact of verbal and nonverbal actions, identify potential issues, and adjust accordingly. Even small changes can make a large difference in patients’ perceptions about attitude and the clinical encounter. For example, maintaining eye contact, sitting while talking to the patient, and avoiding distractions and interruptions can help convey that the physician respects the patient, is interested in hearing the patient’s concerns, and is dedicated to helping the patient.
Empathy, another important soft skill, also is crucial in the clinical encounter. Empathy is not merely understanding someone else’s emotions, but actually experiencing them. Research has shown that greater physician empathy is associated with better clinical outcomes for patients. Unfortunately, studies also have shown that medical education and training can erode physician empathy, which may have detrimental downstream effects on doctor-patient relationships. If patients believe clinicians lack empathy, they may be less willing to share pertinent information and more likely to have unsatisfactory care experiences.
Beyond education and training, cultivating empathy in clinical care can be difficult for various reasons, including the busy practice environment, the myriad patients and conditions encountered, and other stresses (eg, the pandemic and burnout). These issues present challenges, but clinicians can take steps to improve empathy using some of the strategies mentioned previously, such as improving situational awareness, listening skills, and verbal and nonverbal communication. Other approaches also can help build empathy, such as engaging in self-reflective writing, participating in cultural education, and being receptive to ongoing feedback from colleagues and patients.
Overall, a range of soft skills are pivotal in the delivery of high-quality, patient-centred care. Directly linking soft skill deficits to malpractice allegations is not always straightforward due to their subjectivity and the multifactorial nature of claims. However, we do know that these issues can lead to poor patient outcomes, patient dissatisfaction, and patient complaints. A six-year research study on patient complaints and malpractice risk came to the conclusion that:
“Risk seems not to be predicted by patient characteristics, illness complexity, or even physicians’ technical skills. Instead, risk appears related to patients’ dissatisfaction with their physicians’ ability to establish rapport, provide access,
administer care and treatment consistent with expectations, and communicate effectively.”
Undoubtedly, efforts to improve soft skills through various programmes and techniques – such as behavioural coaching, teamwork training, simulation exercises, and surgical timeouts – have contributed to advances in patient safety and patient-centred care, as well as improvements in patient satisfaction and considerable decreases in patient and co-worker complaints. Emerging evidence also shows that enhancing soft skills can benefit physicians by cultivating better doctor-patient relationships, alleviating burnout, and reducing professional liability exposure.
Ultimately, the realisation of high-quality, patient-centred care in modern medicine requires a combination of hard skills (which emphasise technical excellence and medical decision-making) with soft skills (which emphasise emotional intelligence, positivity, communication, and empathy). Together, these skills represent a comprehensive approach to patient care that can produce the best outcomes for both physicians and patients.
Medisec with MedPro offer contractual occurrence professional indemnity insurance to medical practitioners in Ireland.
References available on request
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