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The Four Habits: A Pathway to Healthy Communication

Author: Kirk Pappas, M.D.
October, 2015 Issue

James DeVore, M.D.
All articles by columnist
Author: Kirk Pappas, M.D.
October, 2015 Issue

There’s a huge healing power to the story—both in relationships and in business.


As physicians, one of the many gifts we receive is the relationships with our patients. As you might imagine, the stories we hear are amazing. The life experiences teach us lessons as people, not just as physicians. In my article about resilience [“Resilience as a Vital Sign,” Live Wise, May 2015], I shared one of those stories.

The average time physicians wait after asking patients to tell us their “story” is between 12 and 18 seconds—yes, seconds. But there’s a huge healing power to the story—both in relationships and in business.

Medical schools nationwide are beginning to use actors to train physicians. They’re given the not-so-sexy name of “standardized patients” or “SPs.” They use standardized stories, diseases and conditions, then give feedback to the medical students. Within Kaiser Permanente, we’ve developed similar programs to let physicians practice listening to patients’ stories while being videotaped. Recently, one of our newer physicians described the experience as “eye and ear” opening. The feedback let him clearly see his own body language, active listening and thoughtful responses. These programs aren’t new. More than 15 years ago, I went through a similar one and my experience was identical.

A successful strategy outlined in a 2005 article titled “The Four Habits Model” by Terry Stein, M.D., a Northern California Kaiser Permanente physician, and her colleagues from Harvard and Indiana University, is something I try to revisit every time I have a challenging email, phone call, in-person meeting or even a public speech.

An internal survey at Kaiser Permanente found departments that use the model's guidelines reduced lost work days from injury and illness, improved employee retention, improved productivity, and that an employee who uses the model is 11 times more likely to have job satisfaction. Here are the four habits. 

1. Connect: Invest in the beginning. Intent is important. Approach the interaction in a positive way. If in-person, use a greeting with a social context and ask something about how the other person is doing first. This makes the personal connection and sets the foundation for a successful interaction. Acknowledging the purpose of the conversation (even if initiated by the other person) is powerful. Make sure you address them as they’d like you to, using the correct name and mister, misses, sir or miss. (You never realize how much you can make an 80-year-old woman feel connected until you call her Miss; try it, this is a freebie.) Body language, eye contact and sitting at the same level as the person all make a difference. Ask questions like: “What would you like help with today?” or say, “I hear that you’re here for (blank). Could you tell me more about that?” 

2. Ask: Elicit their perspective. When possible, let the person tell their story first. Let them speak uninterrupted for at least a minute or two (practice with your iPhone and see how hard this is). By doing so, you can count on a better outcome. Be open to ideas around the issue they (or you) are bringing up. Sometimes, this is the best time to ask things like: “What ideas do you have to clarify or solve the problem?” or “What have you tried to deal with/solve the problem?” Let them know where you need clarification.

3. Respond with empathy. This is priceless. For a three-minute lesson on “Empathy vs. Sympathy,” review this video by Brene Brown Make an empathetic statement such as, “It looks like you’re….” or “It seems you’re frustrated/worried (label the emotion you’re sensing from them)” or “It sounds like you’re needing some help.” After they answer, you can respond with, “I’ve had other patients/friends/colleagues/family who’ve experienced a similar problem, so I can understand what you’re going through.”

This is also when the power of the “pause” and letting their thoughts and emotions hang in the air creates a connection. Empathy is the key in this plan.

4. Educate: Invest in the end. This one is about how you close the interaction. As a physician and teacher, this is key for me. Restate what you talked about. Discuss the options and plan the next steps. Agree to the next time you’ll engage, speak or communicate. Then ask: “Did you get what you needed?” “Are there any further questions or concerns?” “Please tell me what you heard during our talk today.”

As leaders, parents, business owners and humans, there’s much to learn about communication. While the world has moved to 140 characters, emoticons and text messaging, the story of life is one best experienced with healthy interactions. Be well.


Kirk Pappas, M.D., is a board certified physical medicine and rehabilitation doctor. He’s the physician-in-chief of the Kaiser Permanente Medical Center in Santa Rosa.


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