Abstract
Patient-physician communication is an integral part of clinical practice. When done well, such communication produces a therapeutic effect for the patient, as has been validated in controlled studies. Formal training programs have been created to enhance and measure specific communication skills. Many of these efforts, however, focus on medical schools and early postgraduate years and, therefore, remain isolated in academic settings. Thus, the communication skills of the busy physician often remain poorly developed, and the need for established physicians to become better communicators continues. In this article, the authors briefly review the why and how of effective patient-physician communication. They begin by reviewing current data on the benefits of effective communication in the clinical context of physicians caring for patients. The authors then offer specific guidance on how to achieve effective communication in the patient-physician relationship.
The manner in which a physician communicates information to a patient is as important as the information being communicated. Patients who understand their doctors are more likely to acknowledge health problems, understand their treatment options, modify their behavior accordingly, and follow their medication schedules.
1-4 In fact, research has shown that effective patient-physician communication can improve a patient's health as quantifiably as many drugs—perhaps providing a partial explanation for the powerful placebo effect seen in clinical trials.
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Decades ago, physicians were presumed to hone their “soft” communication skills at patients' bedsides, in their rounds as residents, and as students at the elbows of master clinicians. Today, the communication and interpersonal skills of the physician-in-training are no longer viewed as immutable personal styles that emerge during residency but, instead, as a set of measurable and modifiable behaviors that can evolve. Based on emerging literature on the value of effective communication, medical students and postgraduates are increasingly given instruction on techniques for listening, explaining, questioning, counseling, and motivating. As such techniques are central to delivering a full and tailored health prescription, 65% of medical schools now teach communications skills.
5 Training in patient-physician communication is also now objectively evaluated as a core competency in various accreditation settings, including the Comprehensive Osteopathic Medical Licensing Examination—USA—Performance Evaluation, the United States Medical Licensing Examination, and the American Board of Medical Specialties' certification.
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These efforts to improve and measure communication skills are timely, as the barriers to effective communication between patients and physicians are growing (
Figure 1). Despite evidence indicating that the average length of the patient-physician encounter has not changed significantly in recent years,
9 specific survey data indicate a correlation between patient participation in capitated health plans and shorter office visits.
10,11 Further, hurdles arising from linguistic and cultural differences, already abundant, will only increase in coming years.
12,13 Medical information and support groups found on the Internet, while potentially a great asset in educating and motivating patients toward better health, have many physicians questioning their traditional role as most trusted counselors.
14,15 However, even demands associated with time, language, and technology––as Internet-available information, which potentially limits face-to-face opportunities––are not an excuse for neglecting one's communication skills. During the typical 15- or 20-minute patient-physician encounter, the physician makes nuanced choices regarding the words, questions, silences, tones, and facial expressions he or she chooses. These choices either enhance or detract from the overall level of excellence of the physician's delivery of care.
The first purpose of this article is to remind physicians of the importance of, and the opportunities for, more effective communications. The second purpose is to offer physicians practical techniques for improved communication with patients.
Medical professionals debate the best strategies for effective communication, as well as the ability of these strategies to be taught or evaluated objectively.
5,6,8 Certainly, each physician must develop his or her own style of communication. At the same time, many professional and academic organizations have now also defined key elements of communications skills needed by physicians. For example, the Accreditation Council for Graduate Medical Education recommends that physicians become competent in five key communication skills: (1) listening effectively; (2) eliciting information using effective questioning skills; (3) providing information using effective explanatory skills; (4) counseling and educating patients; and (5) making informed decisions based on patient information and preference.
6,29 Although these and similar lists of recommended patient-physician communication strategies are valid and useful, these tips are frequently found only in academic or specialty journals or on the checklists now used to rate physicians in-training.
To help practicing physicians gain and strengthen an effective and personal communication style, and, thus, improve patient-physician communication and rapport, we have assembled our own list of practical steps. We hope that these tips, based on our years of clinical experience and our reading of the recent literature on patient-physician communication, will remind colleagues that they are more than a passive conduit of medical information for their patients; they are interpreters and shapers of their patients' health and full partners in their patient's long-term health status.
1. Assess What the Patient Already Knows
Before providing information, find out what a patient already knows about his or her condition. Many times, other physicians or health care providers have already communicated information to the patient, which can have the effect of coloring patient perceptions and perhaps even causing confusion when new information is introduced. For instance, a nephrologist may talk about the patient “getting better” based on improving renal function tests, while a cardiologist is focused on the patient's severe, irreversible cardiomyopathy. In other scenarios, patients will come to the physician with preconceived notions about a particular condition, perhaps based on lessthan-authoritative sources. It is important, therefore, to determine what a patient already understands—or misunderstands—at the outset.
2. Assess What the Patient Wants to Know
3. Be Empathic
4. Slow Down
5. Keep it Simple
6. Tell the Truth
7. Be Hopeful
8. Watch the Patient's Body and Face
Much of what is conveyed between a physician and patient in a clinical encounter occurs through nonverbal communication.
For both physician and patient, images of body language and facial expressions will likely be remembered longer after the encounter than any memory of spoken words.
It is also important to recognize that the patient-physician encounter involves a two-way exchange of nonverbal information. Patients' facial expressions are often good indicators of sadness, worry, or anxiety. The physician who responds with appropriate concern to these nonverbal cues will likely impact the patient's illness to a greater degree than the physician wanting to strictly convey factual information. At the very least, the attentive physician will have a more satisfied patient.
Conversely, the physician's body language and facial expression also speak volumes to the patient. The physician who hurriedly enters the examination room several minutes late, takes furious notes, and turns away while the patient is talking, almost certainly conveys impatience and minimal interest in the patient. Over several such encounters, the patient may interpret such nonverbal behavior as a message that his or her visit is unimportant, despite any spoken assurances to the contrary. Thus, it is imperative that the physician be aware of his or her own implicit messages, as well as recognizing the nonverbal cues of the patient.
9. Be Prepared for a Reaction
Patients vary, not only in their willingness and ability to absorb information, but in their reactions to physician communications. Most physicians quickly develop a sense for the various coping styles of patients, a range of human reactions that has been categorized in several specific clinical settings.
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For instance, a certain percentage of individuals will meet almost any bad medical news in a nonemotional, stoic manner. The physician, however, should not interpret this nonreaction as a lack of patient concern or worry. In some cases, these same individuals go on to exhibit distress by other means (eg, an increased reporting of physical symptoms, additional nonverbal communication of pain, or other behaviors aimed at gaining the attention of the treatment team).
At the other end of the emotional spectrum, the sizable proportion of patients with mild or diagnosable depression and/or anxiety will likely react to bad news with frank displays of crying, denial, or anger.
A small percentage of patients who have difficulty forming a trusting relationship with a physician may react to bad news with distrust, anger, and blame. For such patients, establishing a lasting bond of trust with their physicians can be extremely difficult, and although all attempts to communicate should be made, unsettled feelings on both sides are to be expected.
In responding to any of these patient reactions, it is important to be prepared. The first step is for the physician to recognize the response, allowing sufficient time for a full display of emotions. Most importantly, the physician simply needs to listen quietly and attentively to what the patient or family are saying. Sometimes, the physician can encourage patients to express emotion, perhaps even asking them to describe their feelings. The physician's body language can be crucial in conveying empathic concern in these encounters.
The patient-physician dialogue is not finished after discussing the diagnosis, tests, and treatments. For the patient, this is just a beginning; the news is sinking in. The physician should anticipate a shift in the patient's sense of self, which should be handled as an important part of the encounter—not as an unpleasant plot twist to a physician's preferred story line.