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," Suchman and associates [2] observed that patients seldom verbalized their emotions directly and spontaneously. Instead, they offered clues. Unfortunately, the physicians in this study often passed over the clues and even ignored direct expressions of affect in their pursuit of an exploration of symptoms. A physician displaying such a lack of skill in therapeutic dialogue is like a surgeon ignoring a bleeder in an operative field. Another study [3] showed that physicians without malpractice claims tended to encourage patient talk, solicit opinions, check understanding, and alert patients to the flow of the visit more often than did physicians with malpractice claims.

Faculty trained by the American Academy on Physician and Patient, the Society of Teachers of Family Medicine, and others are beginning to influence medical school curricula. Many introductory clinical medicine courses now try to emphasize that the medical interview is more than a set of open- and closed-ended questions asked to obtain a comprehensive medical history. The new approach to the medical interview teaches a set of core clinical skills for gathering diagnostic information, building a therapeutic relationship, and counseling patients about treatment. The contemporary medical interview is a healing dialogue between physician and patient; it is the major method of making a diagnosis and is an essential component of every therapy [4]. For illness manifested by somatization, therapy that lacks a healing dialogue usually fails.

Although taking a medical history, performing a physical examination, and carrying out procedures are considered "learnable" skills, expressing empathy and listening to patients and their families are thought of as "personality traits." This suggests that the former skills are teachable, whereas the latter are enduring characteristics not influenced by education. Smith and associates [5], in this issue, add to the growing evidence to the contrary; that is, they show that these "traits" can be changed through education. They found that a 1-month formal educational experience focused on the development of specific communication skills changed several important things: knowledge about the role of affect in medical encounters, attitudes toward commitment and self-efficacy in using an expanded interview model, and success in using specific interview and affect management skills with real and simulated patients.

The study compared pre- and post-training ratings of first-year residents in internal medicine and family practice. The study group participated in a 1-month block experience of lectures, interviews with observed patients, and feedback about the interviews. Small group sessions also explored the personal affect generated by the interview experience. Not surprisingly, knowledge about the interview model increased. Equally important, attitudes toward the interview model improved.

A major contribution of the study by Smith and associates is the demonstration that the residents who completed the rotation spoke with and related to both real and standardized patients differently than did the control residents. Patients and their physicians may differ about the importance to overall health of the physician's allowing the patient to talk, responding to the patient's emotions, pursuing psychosocial issues, building rapport, and being patient centered. Yet in encounters with real patients, the residents who had completed the training performed significantly better in these areas than did the residents without training. When both groups were tested by using standardized patients, data-gathering skills, motivational interviewing skills, and skills for managing difficult emotion in somatizing patients were better in the study group than in the control group. These are not trivial skills. They are the crux of competent medical care, particularly from the patient's-and the public's-point of view.

Two other important observations were made in this study. First, no difference was seen between the two groups in the collection of biological or medical information. Second, the study limited the period of analysis to the first 15 minutes of the interview for real patients and to 15 minutes for standardized patients. Because the analysis in both the study and the control group interviews was subject to the same time limitation, the enhanced communications skills were observed during these brief periods rather than elsewhere in the encounter; these changes did not affect the accuracy or efficiency of the medical data gathering during the observed segment.

It is disappointing that the authors were unable to show a difference between the two groups of residents in the health, functional status, and satisfaction of their patients. However, the short follow-up period and the patients' high baseline level of health and functional status would have required a much larger study sample to show a difference (a ceiling effect). Similarly, the level of satisfaction of the patients in both groups was so high that it would be difficult to detect a difference.

The course described by Smith and associates draws attention to the pioneering work of members of the American Academy on Physician and Patient in training faculty and practicing physicians to hone their interviewing, empathic understanding, and counseling skills. One-day, weekend, and 5-day courses sponsored by this organization combine multiple educational formats into a rich, learner-centered experience. Lectures and projects teach a conceptual model of clinical dialogue. Students, working in small groups, practice with real and simulated patients. Guided by a facilitator, they learn by interviewing, observing, and receiving and giving feedback. What is different in these courses is the attention paid to the interviewer's emotional communication through organized discussions using "support group," "Balint group," "family of origin," or "meaningful experience" approaches. Learners experience and express empathy through an awareness of how personal characteristics, past experiences, values, attitudes, and biases influence patient care and one's satisfaction with doctoring [6].

Where is all of this taking us? The subject of physician-patient communication has progressed beyond a few lectures on the "art of medicine" offered by esteemed professors to first- and second-year medical students to a field worthy of serious study and practice. Based in psychology and fortified with advances in communications science, the practice cannot be taken for granted. For the past 20 years, a small, dedicated, and relatively obscure band of devotees has explored physician communication as a diagnostic and treatment tool. Their study is paying off. Now it is time for all physicians to take the dialogue between patient and physician as seriously as they take prescriptions, tests, and surgery.

How will every physician hone interviewing and counseling skills? The answer begins with the dedicated physicians and behavioral scientists who regularly teach courses offered by the American Academy on Physician and Patient and the Society of Teachers of Family Medicine for medical school and residency program faculty. The American College of Physicians, the American Academy on Physician and Patient, the Northwest Center for Physician Patient Communication, and the Bayer Institute for Health Care Communications offer courses for practicing physicians.

By using teaching methods like those described by Smith and associates, these courses could ultimately offer all physicians an opportunity to improve their medical interviewing skills. In time, all medical schools and residency programs will teach medical dialogue as a routine part of daily rounds, and every physician who talks with patients can learn and use the principles and skills of effective clinical dialogue in continuing medical education courses.

Because clinical dialogue affects patient and physician satisfaction, the occurrence of malpractice claims, and clinical outcomes, it is arguably more important than many other lessons that occupy large segments of medical student, resident, and continuing education curricula. We should provide the time and faculty resources that teaching and mastering medical dialogue demand. Unfortunately, the real push to improve physician communication will probably come from patients who are fed up with "doctors who don't listen" and managed care organizations that view patient satisfaction and physician satisfaction as good business. Isn't it time that the profession embraces, as worthy of its best talent and energy, the core clinical skill of dialogue?