The Relationship Between Time Spent Communicating
and Communication Outcomes on a Hospital
Michael B. Rothberg, MD, MPH1,2,3,5, John R. Steele4, John Wheeler, MD2,3, Ashish Arora, MD2,3,
Aruna Priya, MS1, and Peter K. Lindenauer, MD, MSc1,3
1Center for Quality of Care Research, Springfield, MA, USA;2Division of General Medicine, Baystate Medical Center, Springfield, MA, USA;3Tufts
University School of Medicine, Boston, MA, USA;4Dartmouth College, Hanover, NH, USA;5Division of General Medicine and Geriatrics, Baystate
Medical Center, Springfield, MA, USA.
BACKGROUND: Quality care depends on effective com-
munication between caregivers, but it is unknown
whether time spent communicating is associated with
OBJECTIVE: To assess the association between time
spent communicating, agreement on plan of care, and
DESIGN: Time-motion study with cross-sectional survey.
SETTING: Academic medical center.
PARTICIPANTS: Physicians, patients, and nurses on a
hospital medicine service.
MEASUREMENTS: Hospitalists’formsof communication
were timed with a stopwatch. Physician–nurse agreement
on the plan of careand patient satisfaction with physician
communication were assessed via survey.
RESULTS: Eighteen hospitalists were observed caring for
379 patients. On average, physicians spent more time per
patient on written than verbal communication (median:
9.2 min. vs. 6.3 min, p<0.001). Verbal communication
was greatest with patients (mean time 5.3 min, range 0–
37 min), then other physicians (1.4 min), families
(1.1 min), nurses (1.1 min), and case managers
(0.4 min). There was no verbal communication with
nurses in 30% of cases. Nurses and physicians agreed
most about planned procedures (87%), principal diagno-
sis (74%), tests ordered (73%), anticipated discharge date
(69%) and least regarding medication changes (59%).
There was no association between time spent communi-
cating and agreement on plan of care. Among 123
patients who completed surveys (response rate 32%),
time physicians spent talking to patients was not corre-
lated with patients’ satisfaction with physician communi-
cation (Pearson correlation coefficient = 0.09, p=0.30).
CONCLUSIONS: Hospitalists vary in the amount of time
they spend communicating, but we found no association
between time spent and either patient satisfaction or
nurse-physician agreement on plan of care.
KEY WORDS: communication; hospital medicine; outcomes.
J Gen Intern Med 27(2):185–9
© Society of General Internal Medicine 2011
numerous healthcare providers and other professionals in the
careofasinglepatient.Inthissetting,thehospitalist’s roleis that
of team leader, coordinating the efforts of consultant physicians,
nurses, case managers and others. Good teamwork, in turn,
requires effective communication so that all the team members
share a common understanding of the plan and goals of care. In
addition, effective communication between physicians, patients,
and their families is necessary to create a comfortable and
trusting care environment.
Studies conducted at single institutions in the US1–3and
elsewhere4–6have found that hospitalists generally spend little
time communicating with their patients, and that there is often
disagreement between doctors and both nurses and patients
about the plan of care.7,8However, it is not known how much
time physicians actually spend communicating with nurses and
other physicians, and more importantly, whether more time
spent communicating is associated with higher levels of agree-
ment regarding the plan of care or greater patient satisfaction.
We performed a time-motion study to determine how much
time hospitalists spend communicating with nurses, patients,
other physicians,and families,and totestwhetherthe amount of
communication was related to patient satisfaction, or to agree-
ment on the plan of care among physicians, nurses and patients.
Design, Setting and Subjects
During July and September of 2008, we conducted a time-
motion study on the hospital medicine service at Baystate
Medical Center, a 670-bed tertiary care teaching hospital in
Springfield, MA. On each study day, one hospitalist volunteer
was recruited to participate in the study; all were employees of
the Baystate Medical Practices, and cared for approximately
Electronic supplementary material The online version of this article
(doi:10.1007/s11606-011-1857-8) contains supplementary material,
which is available to authorized users.
Received December 17, 2010
Revised June 13, 2011
Accepted August 14, 2011
Published online September 16, 2011
10–14 previously admitted, non-critically ill patients each day
on a non-teaching service. Together with Baystate Medical
Center, the Baystate Medical Practices are a wholly owned
subsidiary of Baystate Health, a large integrated delivery
system in Western Massachusetts. The study was approved
by the Institutional Review Board of Baystate Medical Center.
Observation Methods, Communication Measures
Toestimatethe timehospitalistphysicians spent communicating
with their patients and other caregivers, two of the investigators
shadowed participants over the course of at least one entire day
shift (8 a.m. to 4 p.m.), using a stopwatch to measure the time
each physician engaged in any written or verbal communication
activities. The duration of each individual communication en-
have multiple entries for each patient in each category; these
were later summed to quantify communication time per patient
for that category. For the purposes of the study, written
communication was defined as placing orders, sending alpha-
numeric pages, and reading and writing notes in the written or
electronic medical record. Verbal communication was defined as
any verbal interaction with nurses, patients, their families, other
physicians, and case managers either face-to-face or by tele-
phone. Investigators also recorded whether the patient could
speak, could speak English, the number of days the patient had
been in the hospital, and whether the patient was assigned tothe
physician. Most physicians were shadowed twice, weeks or
months apart. Because more than one study physician might,
on different days, care for an individual patient, a single patient
could be represented in the study multiple times.
Our primary study outcome was the level of agreement
between physicians and nurses and the level of agreement
between physicians and patients on the “plan of care.” Ques-
tions designed to assess agreement about the plan of care were
adapted from a study by O’Leary,7and included the diagnosis,
anticipated tests, treatments, medication changes and consul-
tations, as well as the expected date of discharge. A secondary
outcome of the study was the patients’ assessment of the quality
of communication with their physicians, and their overall
satisfaction with care. Both outcomes were assessed by means
of a written survey (made available in both English and Spanish)
that patients were encouraged to complete and place in a sealed
envelope for pick-up each day. This survey consisted of 11
questions, including 4 about the communication skills of their
physician, 6 about the plan of care, and an overall satisfaction
rating for the hospital experience (Appendix 1 – available online).
Questions about communication were derived from Hospital
Consumer Assessment of Healthcare Providers and Systems
Survey (HCAHPS) and included how frequently the physician
treated the patient with courtesy and respect, listened carefully,
explained things in a way the patient could understand, and
involved the patient or family in the decision making.9Answers
were multiple choice (never, sometimes, usually or always) and
scored on a 4-point scale with a total range from 4 to 16 with a
higher score representing better communication. For every
patient, the physician and day-shift nurse caring for the patient
that day were asked to complete a brief 6-question survey about
the plan of care which mirrored that of the patient (Appendices 2
and 3 – available online). All surveys were collected at the end of
the day. Agreement between a physician and a nurse when both
answered the question (the physician–nurse dyad) was assessed
by 2 independent reviewers and discrepancies were resolved by
a third reviewer. For the question about expected discharge
date, answers were categorized as today, tomorrow, or ≥2 days.
We report means, standard deviations or medians, and inter-
quartile ranges for the amount of time physicians spent engaged
spent on written vs. verbal communication was compared using
the sign test. We used the Pearson and Spearman correlation
coefficients to examine the relationship between the duration of
of the quality of physician-patient communication. Similarly, we
assessed the correlation between each physician’s mean time
spent communicating and mean patient ratings of the quality of
communications. We examined the association between patient
characteristics, hospital day, and geographic assignment with
time spent by hospitalists via Kruskal–Wallis tests. We also
assessed the association between verbal communication times
and the agreement on the plan of care for hospitalist-patient and
hospitalist-nurse dyads via Kruskal–Wallis tests. Agreement
analyses between the two independent reviewers are presented
via Kappa statistics and overall percent agreement. After resolu-
tion of differences by a third reviewer, agreement of physician–
nurse and physician-patient responses on aspects of plan of care
were assessed by percent agreement among cases with paired
assessments available. Time spent by the physician communicat-
ing with the nurse was compared by agreement status via
Kruskal–Wallis. Differences in agreement between physician–
nurse and physician-patient based on their geographical assign-
ment were assessed via a chi-square test. All analyses are done
using SAS 9.1.3 (SAS Institute Inc., Cary, NC, USA).
Atotalof18hospitalists whocaredfor379 patients wereobserved
over the course of 2 months. Twelve physicians were observed on
two separate occasions, 5 were observed only once, and 1 was
observed 3 times. Of the patients, 34 were included twice, 7 three
times, and 1 patient 4 times. We observed substantial variation in
communication practices among the physicians included in the
study. All reported values are means, unless otherwise specified.
On average physicians spent 20.4 minutes each day engaged in
communication activities for each patient that was on their
service, but the interquartile range was 10.8 to 26.4 minutes
and the total range was 0 to 158 minutes (Table 1). Physicians
spent more of this time communicating via written methods than
verbally (median: 9.2 min. vs. 6.3 min., p<0.001). Talking with
patients (5.3 min) was the largest individual component of time
engaged in verbal communication; conversation with other
physicians (1.4 min), families (1.1 min), nurses (1.1 min), and
case managers (0.4 min) occupied a smaller share (Fig. 1). The
mean time spent by a hospitalist on direct verbal communication
Rothberg et al.: Physician Communication
amount of time spent speaking with individual patients ranged
from 0 to 37 min per patient (median 3.9 min).
Hospitalists spent more time communicating with patients
who were able to speak, than with those who could not (median:
4.0 min vs. 1.7 min, p=0.005). Hospitalists also spent more time
with patients during the first 2 days of hospitalization than on
subsequent days (median: 4.8 min vs. 3.7 min, p=0.007). There
was no difference in the time spent speaking with patients
according to whether or not the hospitalist was geographically
assigned to the same patient care unit as the patient (median:
3.7 min. vs. 4.1 min., p=0.76) or according to the patient’s ability
to speak English (median: 4.0 min for English speakers vs.
3.1 min. for non-English speakers, p=0.37). There was limited
verbal communication between the hospitalists and either
nurses (median 0.6 min, IQR 0 to 1.3 min) or other physicians
(median 0 min, IQR 0 to 1.5 min). Hospitalists did not engage in
any verbal communication with nurses for 30% of the patients or
with other physicians for 62% of the patients.
Agreement on Plan of Care
Of the 379 patients cared for by the hospitalists studied, 117
(31%) patients responded to one or more questions on the plan of
care; hospitalists completed plan of care assessments on 186
(49%) patients, and nurses on 141 (37%) patients. There were
116 dyads of nurse-physician assessments (where the nurse and
physician completed assessments on the same patient) and 49
dyads of patient-physician assessments. The two independent
raters agreed >85% of the time on all comparisons except for
physician–nurse assessments of medication changes, on which
the agreement was 84%. All discrepancies were resolved by a
third reviewer. Physicians and nurses agreed 74% of the time on
the patient’s principal diagnosis, 73% on tests ordered, 87% on
consultants, and in 69% of instances on the anticipated dis-
charge date. The median time the physician and nurse spent
communicating verbally was not higher for those cases where
there was agreementthanfor cases ofdisagreementfor diagnosis
(0.6 minvs. 0.7min, p=0.82), tests (0.7minvs. 0.6min,p=0.04),
procedures (0.7 min vs. 0.7 min, p=0.92), medication changes
(0.6 min vs. 0.7 min, p=0.34), consultants (0.6 min vs. 0.7 min,
p=0.90), or discharge date (0.7 min vs. 0.4 min, p=0.10).
Physicians and patients agreed 70% of the time about diagnosis,
67% on tests ordered, 51% on planned procedures, 55%
regarding medication changes, 48% for consultants, and in
70% of instances regarding anticipated discharge date. In cases
where patients and physicians disagreed about diagnosis, there
was longer verbal communication than in cases where they
agreed (median: 6.9 min vs. 2.8 min, p=0.03). For other
dimensions of the plan of care, verbal communication times with
patients were not higher for cases of agreement than for cases of
disagreement. There was no difference in agreement based on
geographical assignment, except that physicians and nurses in
the same geographic area were less likely than those in other
geographic areas to agree regarding medication changes (47.1%
vs. 66.7%, p-value=0.03).
Communication Time and Patient Satisfaction
One hundred and twenty-three patients completed communi-
cation and satisfaction surveys on 16 physicians (response
rate 32%). In general, communication ratings were high
(median score 12, IQR 11 to 12). More time spent communi-
Table 1. Time Physicians Spent Engaged in Different Forms of
Communication, per Patient
IQR (Mins) Total Range
10.8 – 26.4
5.1 – 14.5
0.5 – 3.5
2.4 – 9.5
0 - 2.4
3.7 – 12.1
2.0 – 7.2
0 - 1.3
0 - 0
0 - 1.5
0 - 0.4
0 - 158.0
0 - 70.8
0 - 17.9
0 - 59.1
0 - 13.7
0 - 146.9
0 - 37.0
0 - 45.0
0 - 72.8
0 - 67.8
0 - 21.2
Figure 1. Hospitalist time spent per patient on different types of
verbal and written communication.
Figure 2. Individual physicians’ communication times per patient
(median and interquartile ranges).
Rothberg et al.: Physician Communication
cating with a patient had a weak positive correlation with that
patient’s rating of overall physician communication but it was
not statistically significant (Pearson correlation coefficient =
0.09, p-value=0.30). Similarly, there was no statistically
significant correlation between time spent and any single
component of the communication score. Physicians who spent
more time with patients on average did not have significantly
higher mean scores than physicians who spent less time
(Pearson correlation coefficient = 0.27, p-value=0.31).
In this study of the communication practices of hospitalists
employed by a large integrated delivery system, we found that
on average, physicians spent very little time communicating
directly with patients, nurses and other physicians. Instead,
the majority of communication appeared to take place
through reading and writing of notes and by placing and
receiving patient care orders. We found that physicians and
nurses disagree about the plan of care more than 25% of the
time about key issues such as the admitting diagnosis and
the anticipated discharge date. Agreement between physi-
cians and patients about the plan of care was worse than
between physicians and nurses. We also found a lack of
correlation between the amount of time the physician spent
communicating and the level of agreement between physi-
cians and either nurses or patients about the plan of care.
Finally, we observed no statistically significant correlation
between the amount of time physicians spent communicating
and patients’ evaluations of the quality of the physicians’
Previous studies describing how hospitalists spend their
time have been conducted in various settings, yet report
similar time spent in direct patient care (analogous to our
verbal communication with patients and families), ranging
from 10% to 18% of a shift.1–3,5,6Similarly, we found that
physicians spent 5.3 minutes per patient—about 13% of an 8-
hour shift. We also found that communication times varied
substantially by provider, from a mean of 2 minutes per
patient to greater than 12 minutes per patient.
Other studies have measured duration of communication
between doctors and nurses or communication outcomes, but
none has linked the two. Tipping et al. found that doctors
spent an average 2.2 minutes per patient communicating with
nurses.3O’Leary et al. has studied agreement on the plan of
care, using the same metrics we employed.7,8,10They found
that agreement between physicians and nurses was greatest
for procedures planned (89%) and least for discharge date
(64%)—almost identical to the proportions we observed. Agree-
ment between physicians and patients was also poor, and
similar to what we observed.8There was no communication
reported between physicians and nurses 38% of the time;
agreement was not associated with reported communication
but duration of communication was not measured.7
Our study has a number of limitations. First, it was
conducted at a single institution with a relatively limited
number of hospitalists. Even so, the total amount of time
spent communicating and the time spent on verbal communi-
cation with patients is similar to that reported by others, so the
amounts of time spent in other forms of communication (i.e.,
writing notes, speaking with nurses) may also be generalizable.
Further, our hospitalists were not performing admissions
during the shifts when they were observed. Hospitalists
engaged in admitting patients may have different patterns of
communication. Second, the scores we observed for commu-
nication satisfaction were uniformly high, making it difficult to
differentiate among providers. We relied on questions from the
HCAHPS survey, but an instrument with greater discrimina-
tion might have revealed an association between more com-
munication and higher patient satisfaction. Alternatively, if we
had observed a larger number of encounters, the observed
association may have reached statistical significance. Third,
our response rate was less than 50%, and there was
substantial missing data about the plan of care for both
nurses and patients who either could not or chose not to
complete the forms. Their experiences may have differed
from those nurses or patients who chose to complete them.
Here, too, our findings were almost identical to studies with
much higher response rates. Finally, the physicians in our
study knew that they were being observed and this might
have affected their behavior. We think it would be challeng-
ing for them to alter their clinical practice in the hectic
hospital environment, but if they did so, they would likely
have spent extra time in verbal communication. In that
case, our findings may represent the upper limits of
communication and agreement on plan of care.
In a recent poll of US adults aged 50 years and older,
almost 75% said they wished their doctors talked to each
other.11Our finding that hospitalists did not speak to any
other physician involved in the patient’s care in 62% of
encounters is disappointing in this regard. Instead, doctors
communicated via written notes without the opportunity to
ask clarifying questions. Subsequent decisions may be
made without complete information, and patients may
receive contradictory information from different consultants
unaware of each others’ plans.
Presumably, patients would also like their doctors and
nurses to speak with one another. Patients interact primarily
with nurses and expect the nurse to be a knowledgeable
member of the healthcare team. We suspect that many
patients would be surprised to learn that their physician
often did not speak to their nurse at all, and when they did,
the median time was only 30 seconds. However, we found no
correlation between physician–nurse communication times
and agreement on the plan of care, so presumably this
communication centers around something else. This same
disconnect existed for physician–patient communication.
Doctors who spent more time with patients did not receive
higher ratings on communication skills, nor were their
patients more likely to correctly understand the plan of care.
If hospitalists wish to improve understanding, they cannot
simply spend more time communicating, they have to
communicate more effectively.
Communication is important for two reasons. First, hospital
care is complex, requiring coordination of a therapeutic team,
under the leadership of a hospitalist. Without effective commu-
nication, teamwork suffers and errors are likely to occur.
Although 87% agreement between physicians and nurses on
be tolerated in other industries. For example, airlines’ lost
luggagerates are lessthan0.3%.Incontrast,medicalprocedures
Rothberg et al.: Physician Communication
are frequently postponed because a patient was allowed to eat Download full-text
due to a lack of communication. Second, although patients have
always participated in their care, there is a growing belief that
patients should be involved in shared decision making, and even
to participate as an active member of the healthcare team. Such
participation is not possible without consistent exchange of
Efforts to improve communication will have to balance
hospitalists’ other responsibilities. Although physicians gener-
ally prefer synchronous communication (e.g., direct communi-
cation in person or by telephone), such communication is
disruptive to work flow.12We found, however, that most
communication took place through asynchronous means, such
as alphanumeric paging, electronic notes, and orders. This lack
of opportunity to clarify may partly explain the frequent
disagreement about the plan of care. Communication might be
improved through multidisciplinary rounding, which has been
shown to improve care quality and decrease mortality in
intensive care units.13,14Such rounds also appear to improve
communication between hospitalists and nurses, though imple-
mentation remains a challenge, and the effects on length of stay
and costs are mixed.15,16
In conclusion, we found that while hospitalists in one
academic center spent limited time communicating directly with
patients, nurses and other physicians, the quality of the
communication, as reflected in agreement on the plan of care
and patient satisfaction, was not associated with the amount of
time spent communicating. Future studies should address ways
to improve the effectiveness of communication without increas-
ing the time burden on hospitalists.
Funding: This study was funded with internal funds from the
Center for Quality of Care Research at Baystate Medical Center.
Prior Presentations: None.
Conflicts of Interest: None disclosed.
Corresponding Author: Michael B. Rothberg, MD, MPH; Division of
General Medicine and Geriatrics, Baystate Medical Center, 759
Chestnut Street, Springfield, MA 01199, USA (e-mail: Michael.
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