PHYSICIAN COMMUNICATION SKILLS
UPLIFT
It’s been said that patients don’t care how much you know until they know how much you care.
PHYSICIAN COMMUNICATION SKILLS
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The Doctor-Patient Relationship
Effective PhysicianPatient Communication
Impacting the Success of Treatment
Physicians’ ability to effectively and compassionately communicate information is key to a successful relationship.
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Build a Good DoctorPatient Relationship
Foster Better Doctor-Patient Communication and Improve Patient Satisfaction
Six Keys to Effective Physician-Patient Interactions
4 Ways to Foster Doctor-Patient Communication
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Guidelines for Improving Communication Skills
Communications Practice for Physicians
The key to success in patient care is a good patient-doctor relationship.
4 Best Practices for Improving Patient-Provider Communication
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31 – 34
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THE DOCTORPATIENT RELATIONSHIP Impacting the Success of Treatment By Carol Eustice
The Relationship The relationship between patient and doctor has been analyzed since the early 1900’s. Prior to when medicine was more science than art, physicians worked to refine their bedside manner, as cures were often impossible and treatment had limited effect. In the middle of the century when science and technology emerged, interpersonal aspects of health care were overshadowed. There is now a renewed interest in medicine as a social process. A doctor can do as much harm to a patient with the slip of a word as with the slip of a knife.
Have you ever wondered what patients want from an encounter with a doctor? In the thoughts of one physician (Delbanco,1992):
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Patients want to be able to trust the competence and efficacy of their caregivers. Patients want to be able to negotiate the health care system effectively and to be treated with dignity and respect. Patients want to understand how their sickness or treatment will affect their lives, and they often fear that their doctors are not telling them everything they want to know.
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Patients worry about the future. Patients worry about and want to learn how to care for themselves away from the clinical setting. Patients want physicians to focus on their pain, physical discomfort, and functional disabilities. Patients want to discuss the effect their illness will have on their family, friends and finances.
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What Are the Effects of an Effective Patient-Doctor Relationship? When the relationship includes competence andcommunication, typically there is better adherence to treatment.
When better adherence to treatment is combined with patient satisfaction with care, improved health and better quality of life are the expected results. Bottom line: The success of treatment can be greatly impacted by the doctor-patient relationship.
Instrumental and Expressive Components
. .
The doctor-patient relationship crosses two dimensions: Instrumental Expressive The “instrumental” component involves the competence of the doctor in performing the technical aspects of care
. . .
such as: Performing diagnostic tests Physical examinations Prescribing treatments The “expressive” component reflects the art of medicine, including the affective portion of the interaction such as warmth and empathy, and how the doctor approaches the patient.
The effectiveness of treatment is largely dependent on the patient carrying out the directions of the physician. Treatment options for arthritis may involve:
Non-adherence to the treatment plan presupposes a negative outcome, with the assumption that:
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. Taking prescribed medications . Range of motion and strengthening exercises . Joint protection techniques . Natural remedies . Pain relief techniques . Anti-inflammatory diet . Weight control . The treatment is appropriate and usually effective. . There is an association between adherence and improved health.
. The patient is able to carry out the treatment plan.
Common Patient-Doctor Relationship Models The Activity-Passivity Model
The Mutual Participation Model
Not the Best Model for Chronic Arthritis
Shared Responsibility
It is the opinion of some people that the differential in power between the patient and doctor is necessary to the steady course of medical care. The patient seeks information as well astechnical assistance, and the doctor formulates decisions which the patient must accept. Though this seems appropriate in medical emergencies this model, known as the activity-passivity model, has lost popularity in the treatment of chronic conditions, such as rheumatoid arthritis and lupus. In this model, the doctor actively treats the patient, but the patient is passive and no control.
In the third model, the mutual participation model, the doctor and patient share responsibility for making decisions and planning the course of treatment. The patient and doctor are respectful of each others expectations, point of view, and values.
The Guidance-Cooperation Model
Some have argued that this is the most appropriate model for chronic illnesses, such as rheumatoid arthritis and lupus, where patients are responsible for implementing their treatment and determining its efficacy. The changes in the course of chronic rheumatic conditions require a doctor and patient to have open communication.
The Most Prevalent Model The guidance-cooperation model is the most prevalent in current medical practice. In this model, the doctor recommends a treatment and the patient cooperates. This coincides with the “doctor knows best� theory whereby the doctor is supportive and non-authoritaran, yet is responsible for choosing the appropriate treatment. The patient, having lesser power, is expected to follow the recommendations of the physician.
Common Patient-Doctor Relationship Models
Not the Best Model for Chronic Arthritis
The Most Prevalent Model
Shared Responsibility
The Activity-
The Guidance-
The Mutual
Passivity Model
Cooperation Model
Participation Model
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“The good physician treats the disease, the great physician treats the patient who has the disease.� William Osler Canadian Physician
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BUILD A GOOD RELATIONSHIP Six Keys to Effective Physician-Patient Interactions By Catherine Hambley, PhD
What are the most significant predictors of patient satisfaction with their physicians? If you think they are technical skills and interventions, such as medical interventions, tests, and examinations), you are wrong. It turns out that what matters most to patients is the quality of their conversations with their doctors specifically, patients care about:
. Being listened to, and having their expectations
. Being involved in decisions about their healthcare
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. Receiving clear explanations about their medical status and treatment
. Being treated courteously and respectfully
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With all this in mind, here are six strategies to ensure the most effective physician-patient
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Remember: no two people are the same
Listen to understand, not to respond
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Minimize your patient’s sense of threat
Acknowledge your patient’s emotions
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Find out what your patient cares about and needs from you
Avoid responding defensively to a patient
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Patients are much more likely to listen to and understand medical advice when they themselves feel listened to and cared about. When patients are facing a difficult medical situation (for example, a new diagnosis, discomfort, or an uncertain outcome), they are in a threat state. Their emotions get triggered, their limbic system gets activated, and their prefrontal cortex starts to deactivate. This results in people not being able to think as clearly, listen well, or appreciate a wider perspective.
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No two people are the same. Don’t assume you know how your patients feel and what they care about. Ask them. Listen to understand, not to respond. Be genuinely curious about what your patients say, what they ask about, and what they understand about their medical situation. Minimize your patient’s sense of threat. There are five factors to consider in helping people feel safe. 1. Predictability — let patients know what to expect. 2. Choice — whenever possible, involve patients in decision making about their medical care. 3. Fairness — often, patients feel it just isn’t fair that they got sick. Help patients know that you will do everything you can to help them through their situations. 4. Acceptance and connection — your patients want to feel that you care about them. Treat them with compassion, respect, and courtesy. 5. Trust — be honest, do what you say you are going to do, and be willing to tell patients when you don’t know something.
Acknowledge your patient’s emotions. Ask open-ended questions about how he sees his situation (“What do you understand about what we have discussed today?”), and let him know you are his partner in health. Find out what your patient cares about and needs from you. (“How can I be most helpful to you in this situation?”). Let patients know what they can expect as it relates to their diagnosis, treatment, and interactions with you, their doctor. Avoid responding defensively to a patient. If your patient gets upset, try to understand what he is concerned about and acknowledge his concerns. Remember, this is a scary time for patients and they are more likely to respond emotionally.Both you and your patients will be happier and healthier for it.
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GUIDELINES FOR IMPROVING COMMUNICATION The key to success in patient care is a good relationship. By Douglas A. Drossman MD
We have all heard the statements starting with William Osler (“90% of the diagnosis comes from the history”) and and from our patients (“My doctor doesn’t have time for me”; My doctor doesn’t listen to me, all she does are tests”, etc.). We also know that the health care system is imploding because of spiraling costs for care and dissatisfied patients. Is there a solution? There is growing evidenced that the key to success in patient care is a good patient-doctor relationship. In this era it doesn’t bring in more money but it may help reduce costs for care. The value of good communication skills and the building of an effective relationship with the patient is supported by several medical studies that show that these skills can lead to improved patient and physician satisfaction, better disclosure of important information, greater adherence to treatment, reduced emotional distress, improved physiological parameters and overall better clinical outcomes. Conversely ineffective communication skills and a poor patient provider relationship are associated with low patient satisfaction and an increase in malpractice claims.
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What do Patients Tell us? From what patients tell us in practice or through reading internet websites we are getting a good view of the patient experience in health care. The quotations below are actual comments that I have been told when seeing my patietns with complex functional GI and motility problems.
“My doctor doesn’t treat me like a person”.
“My doctor doesn’t listen to what I have to say…He doesn’t believe me”.
“I’m getting much better treatment from a holistic doctor”.
“She just tells me what to do”.
“Why aren’t I being treated like other patients….. I feel so alone”.
“Doctors don’t believe me… I know it’s real…There must be something wrong….They really don’t know what I’m going through….sometimes I feel like I’m going crazy”.
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“Why aren’t I being treated like other patients….. I feel so alone”. Many patients do not believe they are receiving proper care and feel isolated from their health care. “Doctors don’t believe me…I know it’s real…There must be something wrong….They really don’t know what I’m going through….sometimes I feel like I’m going crazy”. Patients also feel that their providers do not understand or believe their symptoms and they desperately want to be believed. They have fears that it’s all in the mind and feel isolated almost as “medical orphans”. While it is unlikely that providers have directly communicated such perspectives, there are sufficient patient commentaries to suggest that this is occurring indirectly either by faulty communication through non-verbal behaviors, or by dialog that communicates mixed messages or provider uncertainty. “My doctor doesn’t treat me like a person”. Patients do not feel that their providers fully consider the whole person or explore their life experience. They would like them to understand the impact of their symptoms on work, social and family life, the patient’s expectations and beliefs, and the influence of ethnic or sociocultural mores. “My doctor doesn’t listen to what I have to say… He doesn’t believe me”. There are often discrepancies between the beliefs of patients and their peers (e.g., on the internet) compared to their providers relating to the cause and possible treatments for their conditions, e.g. they may focus on diet and lifestyle while they doctors do not see this as relevant.
“I’m getting much better treatment from a holistic doctor”. Many patients are seeking alternative treatments because they are dissatisfied with the type of care received from their health care providers. Many practitioners of CAM have learned the ways to engage patients effectively. “She just tells me what to do”. Patients want to participate in the decision-making regarding the options for treatment. Those that do not need to be encouraged to do so. Family members are also impacted with chronic illness and need to be involved in the patient’s education and in care decisions. However the patient is primarily responsible. Finally, patients who feel uncertain about their illness and are involved negatively with their health problems (i.e., worried, depressed, helpless and hopeless) tend to be dissatisfied with their care. However, patients are more satisfied with providers who are trained in good communication skills.This further highlights the value of learning these techniques.
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Tips and Strategies The basis for an effective patient provider relationship occurs through proper interview technique. It is patient centered, i.e., based on creating the proper environment that encourages the patient to give personal high quality information, both medical and psychosocial. This occurs through both verbal statements, the behavioral context within which it is said and in relation to facilitative nonverbal behaviors that create a comfortable environment and help create a partnership of care: Listen Actively The clinical data is obtained through an active process of listening, observing and facilitating. Questions should evolve from what the patient says rather than strictly from a predetermined agenda. If uncertain of the patient’s response, it helps to restate the information asking for clarification, and this reaffirms to the patient the provider’s commitment to understand. Accept the Reality of the Disorder Many providers may have difficulty accepting functional GI or other somatic syndromes as bona fide since there is no biomarker or specific diagnostic test. It drives behaviors such as frequently ordering of tests or communicating uncertainty. These are patients who desperately want to be believed. The solution here is to accept the diagnosis as real and focus on the commitment to work with the patient and his/her illness by listening communicating interest and concern and offering support. Stay Attuned to Questioning Style and Non-Verbal Messages Often, it’s not what you say, but how you say it that makes the difference. Table 1 gives examples of several behaviors that either facilitate or inhibit the acquisition of data from the patient. In general, the physician wants to communicate nonjudgmental interest in an environment of comfort, support and security.
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Elicit the Patient’s Illness Schema To properly negotiate treatment, the provider must identify how the patient understands the illness. In doing so a dialog can begin that will lead to a mutually specified set of goals. For example, even with years of symptoms, patients may expect the physician to diagnose a different, structural disease and effect a cure. But the provider sees this as a chronic disorder requiring ongoing management. Thus these differences must be reconciled in order for the patient to accept treatment and cope with the disorder.
Behaviors Influencing Accurate Data Collection
FACILITATES
INHIBITS
Clinical environment
Private, comfortable
Noisy, physical
Eye contact
Frequent
Infrequent or constant
Body posture
Direct, open, relaxed
Body turned, arms
Head nodding
Helpful if well timed
Infrequent, excessive
Body proximity
Close enough to touch
Too close or too
Facial expression
Interest, empathy, understanding
Preoccupation, bore-
Touching
Helpful when used
Insincere if not appropriate or properly timed
BEHAVIOR
FACILITATES
INHIBITS
Open ended to generate hypotheses
Rigid or stereotyped
Closed ended to test
Multiple choice or leading questions (“You didn’t...?)
Use of patient’s words
Use of unfamiliar
Fewer questions and
More
Nonjudgmental
Judgmental
Follows lead of patient’s earlier responses
Follows preset agenda
Use a narrative
Unorganized questioning
BEHAVIOR Nonverbal
Verbal Question forms
Question style
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EFFECTIVE PHYSICIAN-PATIENT RELATIONSHIP Physicians’ ability to effectively and compassionately communicate information is key to a successful relationship. By The American College of Obstetricians and Gynecologists
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Physicians’ ability to effectively and compassionately communicate information is key to a successful patientphysician relationship. The Accreditation Council for Graduate Medical Education identified interpersonal and communication skills as one of six areas in which physicians-in-training need to demonstrate competence. This Committee Opinion reviews interviewing techniques to help the busy obstetrician–gynecologist effectively obtain a complete medical history, and discusses communication skills to assist in effectively relaying treatment plans. Patient outcomes depend on successful communication. The physician who encourages open communication may obtain more complete information, enhance the prospect of a more accurate diagnosis, and facilitate appropriate counseling, thus potentially improving adherence to treatment plans that benefits long-term health. This type of communication, which may be referred to as the partnership model, increases patient involvement in their health care through negotiation and consensus-building between the patient and physician. In the partnership model, physicians use a participatory style of conversation, where physicians and patients spend an equal amount of time talking. The partnership model is one of several communication models that improves patient care and reduces the likelihood of litigation.
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Box 1. Five Fundamentals of Patient Communication Acknowledge
Being attentive and greeting the patient in a positive manner
Introduce
Giving your name, your role, and your skill set
Duration
Giving a reasonable time expectation
Explanation Thank you
Making sure the patient is knowledgeable and informed Showing appreciation to the patient for her cooperation
The RESPECT model, which is widely used to promote physicians’ awareness of their own cultural biases and to develop physicians’ rapport with patients from different cultural backgrounds, includes seven core elements: rapport, empathy, support, partnership, explanations, cultural competence, and trust. (see Box 2)
Box 2. The RESPECT Model Rapport Connect on a social level. See the patient’s point of view. Consciously attempt to suspend judgement. Recognize and avoid making assumptions. Empathy Remember that the patient has come to you for help. Seek out and understand the patient’s rationale for her
Rapport
Empathy
behaviors or illness. Verbally acknowledge and legitimize the patient’s feelings. Support Ask about and try to understand barriers to care and compliance. Help the patient overcome barriers.
Support
Involve family members if appropriate. Reassure the patient you are and will be available to help.
Partnership Partnership Be flexible with regard to issues of control. Explanations
Negotiate roles when necessary. Stress that you will be working together to address
Cultural Competence
medical problems. Explanations
Trust
Check often for understanding. Use verbal clarification techniques. Cultural Competence Respect the patient and her culture and beliefs. Understand that the patient’s view of you may be defined by ethnic or cultural stereotypes. Be aware of your own biases and preconceptions. Know your limitations in addressing medical issues across cultures. Understand your personal style and recognize when it may not be working with a given patient. Trust Self-disclosure may be an issue for some patients who are not accustomed to Western medical approaches. Take the necessary time and consciously work to establish trust.
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Developing effective patient–physician communication requires skill in conducting patient-centered interviews, conversing in a caring, communicative fashion, and engaging in shared decision making with patients. Physicians may consider five steps for effective patient-centered interviewing as shown in Table 1. The following four qualities are important components of caring, effective communication skills: comfort, acceptance, responsiveness, and empathy. Comfort and acceptance refer to the physician’s ability to discuss difficult topics without displaying uneasiness, and the ability to accept the patient’s attitudes without showing irritation or intolerance. Responsiveness and empathy refer to the ability to react positively to indirect messages expressed by a patient. These skills allow the physician to understand the patient’s point of view and incorporate it into treatment.
. . . . . .
Table 1. Five Step Patient-Centered Interviewing Step 1. Set the stage for the interview Welcome the patient Use the patient’s name Introduce yourself and identify specific role Ensure patient readiness and privacy Remove barriers to communication Ensure comfort and put the patient at ease
. . . .
Step 2. Elicit chief concern and set an agenda Indicate time available Forecast what you would like to have happen Obtain a list of all issues the patient wants to discuss Summarize and finalize the agenda
. . .
Step 3. Begin the interview with non-focusing skills that help the patient to express herself Start with open-ended request/question Use nonfocusing open-ended skills Obtain additional data from nonverbal sources
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. . . . . . . .
Step 4. Use focusing skills to learn 3 things: Symptom Story, Personal Context, and Emotional Context Elicit symptom story Elicit personal context Elicit emotional context Respond to feelings/emotions Expand the story Step 5. Transition to middle of the interview Brief summary Check accuracy Indicate that both content and style of inquiry will change if the patient is ready
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“Medicine is an art whose magic and creative ability have long been recognized as residing in the interpersonal aspects of patientphysician relationship.” Journal of Health and Social Behavior
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Foster Better Doctor-Patient Communication and Improve Patient Satisfaction 4 Ways to Foster Doctor-Patient Communication By Schumacher Clinical Partners
Communicating effectively, at a level the patient can understand, is one way to express care. The words you use and the way you use them is central to establishing a positive relationship that can result in improved outcomes both clinically and in patient satisfaction scores as reported in the HCAHPS survey, part of which deals with communication specifically. With that in mind, here are four ways to improve communication that will result in better patient satisfaction. Understand Patient Expectations A patient’s satisfaction is tied to his expectations, which may, at times, be unreasonable. Nonetheless, the physician’s awareness of the patient’s expectations during consultations is vital to achieving effective communication. When the quality of communication is rated highly, patients are more likely to be satisfied with the quality of care they receive. Listen Intently and Actively Look into the patient’s eyes and listen intently and actively. Ask open-ended questions to draw out more information. That’s not new advice, but it bears repeating. With the high-intensity activity that often characterizes life in the ER, taking the time (even though you may not have a lot of it) to stop, look, and listen is priceless. It shows empathy and respect and demonstrates that you value the patient as a human being.
Utilize Mobile Technology Translation apps such as Canopy Speak or MediBabble Translator communicate quickly with patients using translated medical phrases in a variety of languages, including Spanish, Chinese, French, Arabic, Russian, Haitian Creole, and many others. Other apps, like VisualDX, contain thousands of images that you can use to help a patient better understand his condition. Simplify Medical Terms Another way to facilitate effective communication is to simplify the terminology you use. That’s not always easy but speaking in plain English at a level patients can understand can have positive benefits. Patients who better understand their conditions and your recommendations are more likely to take a greater interest in their care. They will ask questions, follow recommendations, and feel less intimidated, making for a better overall experience in the ED. For example, instead of saying “cellulitis,” use the term “skin infection.” Or, in place of “PO” just say “by mouth.” Your patients will appreciate your effort to meet them where they are linguistically.
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Simplifying medical terminology isn’t always easy, but using plain language with patients pays off. Patients who better understand their conditions and your recommendations are more likely to ask questions, follow recommendations, and feel less intimidated, making for a better overall experience in your ED. Need help trading complex terms for simple ones? Here’s a list of common replacements to get you started.
COMPLEX
SIMPLE
Acetaminophen
Tylenol
Analgesic
Pain killer
Attempt
Try
Authorize
Allow, approve
Bacteria
Germs
Benign
Not cancer
Bronchodilator
Drug that helps you breathe better
Carcinoma
Cancer
Cardiologist
Heart doctor
Cellulitis
Skin infection
Cerebral Hemorrhage
Stroke, bleeding in brain
Contusion
Bruise
Demonstrate
Show
Dermatologist
Skin doctor
Economical
Cheap, low cost
Embolism
Blood clot
Facilitate
Help
Gradually
Slowly, over time
Herpes Zoster
Shingles
Hypertension
High blood pressure
Immediately
Right away
Influenza
Flu
Injection
Shot
Jaundice
Skin and eyes turn yellow
Menses
Period
Monitor
Keep track of
Oral or PO
By mouth
Referral
Send to another doctor
Toxic 29
Benefits of Effective Communication An article in NIH PubMed Central entitled “Doctor-Patient Communication: A Review� states that doctors who possess the ability to communicate effectively with patients can expect to benefit in several ways. They can detect problems earlier, prevent medical crisis and expensive intervention, and provide better support to their patients.This may lead to higher-quality outcomes and improved patient satisfaction. As a result, patients will have a more granular understanding of their health issues and a better adherence to treatment protocols. We agree. Without a doubt, it pays to listen, understand, speak plainly and clearly, and use aids such as mobile apps when necessary. It also supports our goal of putting the patient first.
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Communications Practice for Physicians 4 Best Practices for Improving Patient-Provider Communication By Sara Heath
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Include the patient in care coordination While opening lines of communication using new health IT tools presents opportunities for better clinical outcomes, providers should also remember the importance of patient satisfaction during interpersonal exchanges. Including the patient in his own care is an important part of this. Including the patient in care coordination goes a long way in helping him to take ownership of his own health. Sharing with patients the rationale behind a certain procedure, for example, not only puts them at ease, but also makes them feel consulted in that decision-making process. Open lines of communication using health IT
Be clear about using the patient portal Experts have long boasted the benefits of patient portals, saying that patient access to health data is important for them to fully understand their health and treatment plans. However, it is not enough for providers to assume patients will just register for the portals, or simply request they sign up for it. Studies show that patient portal adoption is higher when providers endorse the product. Because patients trust the opinions of their providers, they may be more likely to believe that patient portals will be a useful tool in maintaining their wellness. Providers need to practice their communication skills while trying to foster patient buy-in for the portal. According to Marcia Cheadle, RN, senior director for clinical applications at Inland Northwest Health Services, providers need to show patients how to use the portal before they leave the doctor’s office. “What if instead I said to the patient as they leave the emergency room in my discharge process, ‘hey, let me show you where your information is on your portal.’ What would that look like?” Cheadle said in an EHRIntelligence. com webcast last August. Encouraging patients to use the patient portal opens up additional opportunities for communication. These technologies help patients send messages to providers when they have a health issue, or work with appoint ment scheduling when a conflict occurs.
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Although the robust use of health IT may be seen as a hindrance to genuine connection between patients and providers, it can also be utilized to help increase connectivity, so long as it is used effectively. Patient portals are not the only technological tools that can open lines of communication. Telehealth is a burgeoning healthcare delivery practice that allows patients to connect with the physicians remotely in times of a health emergency. These technologies do a lot to get rid of any barriers to care patients might be facing and to encourage them to connect with their physicians when something may be going wrong. In the long-run, telehealth has the powerto mitigate a health concern before it grows into a issue.
Be empathetic toward the patient Provider empathy in communication is an umbrella principle under which all of these best practices should fall. Providers should approach each exchange between themselves and their patients with sensitivity and compassion as a means to boost patient satisfaction. Studies show that these practices are deeply effective. At Massachusetts General Hospital department for orthopedic surgery, providers who were perceived as more empathetic tended to receive higher patient satisfaction ratings. The researchers also found that 65 percent of patient satisfaction was correlated to provider empathy.
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Bibliography Chapter 01 https://www.verywellhealth.com/the-doctor-patient-relationship-188050
Chapter 02 https://www.physicianspractice.com/patient-relations/six-keys-effective-physicianpatient-interactions
Chapter 03 Balint E. The possibilities of patient-centred medicine. JR College Gen Pract 1969; 17: 269-76. Beckman HB, Markakis et al. "The doctor-patient relationship and malpractice: Lessons from plaintiff depositions." Archives of Internal Medicine 1994; 154: 1365-1370
Chapter 04 Accreditation Council for Graduate Medical Education. ACGME common program requirements. Chicago (IL): ACGME; 2013. Roter DL. Physician/patient communication: transmission of information and patient effects. Md State Med J 1983;32:260–5.
Chapter 05 https://patientengagementhit.com/news/4-best-practices-for-improving-patientprovider-communication
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