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. 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.
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.
Medical professionals debate the best strategies for effective communication, as well as the ability of these strategies to be taught or evaluated objectively. Certainly, each physician must develop his or her own style of communication. At the same time, many professional and academic organizations now also have defined key elements of communications skills needed by physicians. For example, it has been recommended that physicians become competent in five key communication skills:
- listening effectively;
- eliciting information using effective questioning skills;
- providing information using effective explanatory skills;
- counseling and educating patients; and
- making informed decisions based on patient information and preference.
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.
I hope that the following list will remind my 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 already have 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 this scenario, the patient may not fully realize the seriousness of the cardiologist’s findings because the nephrologist has told her that she “is getting better.” In other scenarios, patients will come to the physician with preconceived notions about a particular condition, perhaps based on less-than-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
Not all patients with the same diagnosis want the same level of detail in the information offered about their condition or treatment. Studies have categorized patients on a continuum of information-seeking behavior, from those who want very little information to those who want every detail the physician can offer. Thus, physicians should assess whether the patient desires, or will be able to comprehend, additional information. For the physician without advance knowledge of the patient, this level of need will emerge by degrees as the discussion unfolds and as the physician attempts to synthesize and present information in a clear and understandable manner.
As when obtaining informed consent, a standard first step in presenting information to a patient would be to describe the risks and benefits of the procedure and then to simply allow the patient to decide how much additional information he or she wants. However, this step may require direct questions, strategic silences, and frequent verification that the information is actually being comprehended.
One telling sign of whether the patient is understanding the information is the nature of the questions patients ask; if questions reflect comprehension of the information just presented, a further level of detail may be warranted. If questions reflect confusion, it is advisable that the physician return to basic information. If the patient has no questions or is obviously uncomfortable, this is a good opportunity for the physician to stop the discussion, ask explicitly how much information the patient desires, and adjust accordingly. Continuing to provide further information is not always the best approach.
3. Be empathic
Empathy is a basic skill physicians should develop to help them recognize indirectly expressed emotions of their patients. Once recognized, these emotions need to be acknowledged and further explored during the patient-physician encounter. Further, physicians should not ignore or minimize patients’ feelings with a redirected line of inquiry relentlessly focused on “real” symptoms. Remember that your patients are people, and the consequences for them are more than clinical results. Patient satisfaction is likely to be enhanced by physicians who acknowledge patients’ expressed emotions. Physicians who do this are less likely to be viewed as uncaring by their patients. ANECDOTE.
4. Slow down
Physicians who provide information in a slow and deliberate fashion allow the time needed for patients to comprehend the new information. Other techniques physicians can use to allow time include pausing frequently and reinforcing silence with appropriate body language. A slow delivery with appropriate pauses also gives the listener time to formulate questions, which the physician can then use to provide further bits of targeted information. Thus, a dialogue punctuated with pauses leads to deeper comprehension on both sides.
One study found that physicians typically wait only 23 seconds after a patient begins describing his chief complain before interrupting and redirecting the discussion. Such premature redirection can lead to late-arising concerns and missed opportunities to gather important data.
As a side note, patient satisfaction is also greater when the length of the office visit matches his or her pre-visit expectation. In situations involving the delivery of bad news, the technique of simply stating the news and pausing can be particularly helpful in ensuring that the patient and patient’s family fully receive and understand the information. Allowing this time for silence, tears, and questions can be essential. Currently being on the other side of the doctor-patient relationship, I can tell you firsthand how much my well-being is improved when the physician takes the time to listen and thoughtfully answers my questions.
5. Keep it simple
Physicians should avoid engaging in long monologues in front of the patient. A more successful strategy for the physician is to keep to short statements and clear, simple explanations. Those who tailor information to the patient’s desired level of information will improve comprehension and limit emotional distress. Again, physicians should be sure to ask whether patients have any questions so that understanding can be checked and dialogue promoted. It is wise for the physician to avoid the use of jargon whenever possible, particularly with elderly patients.
An important fact for physicians to keep in mind: between 20% and 40% of U.S. citizens between 60 and 80 years of age have not attained a high school diploma. In patients of all ages, a physician cannot assume the understanding of treatment risks that are described with percentages or numbers. Such “low numeracy skills” of patients require that physicians take special care in outlining the relative risks of diagnostic procedures and treatments. The bottom line is that we need our patients to understand what we are telling them, so we need to be as clear and keep it as simple as possible.
6. Tell the truth
It is important to be truthful. In addition, it is important that physicians not minimize the impact of what they are saying. For example, euphemisms may soften the delivery of sad information but can be extremely misleading and create confusion.
In my case, one of the initial doctors with whom I was working and whom I had known for many years, refused to return my phone calls and when he finally did, he told me to “remember my training” instead of committing to a diagnosis either way. This left me confused and certainly frustrated. Sure, I agree that my situation is complex, but his lack of communication was scary and unprofessional. Needless-to-say, we are not working together today.
Saying that a patient has “gone” or has “left us,” for example, could be interpreted by an anxious family member as meaning that the patient has left his room to have a radiologic film taken or to undergo a test. Alternatively, physicians who use “D” words (e.g., dying, died, dead), when appropriate, effectively communicate the circumstance and minimize confusion. Yes, physicians perform a delicate dance, but as long as they demonstrate compassion while striving for clarity, everyone in the doctor-patient relationship will be well-served.
7. Be hopeful
Although the need for truth-telling remains primary, the therapeutic value of conveying hope in situations that may appear hopeless should not be underestimated. Particularly in the context of terminal illness and end-of-life care, hope should not be discouraged.
In my experience, I have not been given any “pep-talks” or had any discussions about hope. Perhaps that is because my situation is dire, but still, we cannot rule out what hope can do for our overall well being and our state of mind. My husband often reminds me that “Hope is a thing with feathers.” If it were not for him, I would have given up a long time ago. Certainly my physicians have not at all been my cheerleaders.
In situations such as the imminent death of a patient, hope can be conveyed to the family by assuring them that therapy can be effective in allaying pain and discomfort. Thus, even when physicians must convey a grim prognosis to a patient or must discuss the same with family members, being able to promise comfort and minimal suffering has real value.
8. Watch the patient’s (and your own) 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.
For instance, a certain percentage of individuals will meet almost any bad medical news in a non-emotional, stoic manner. The physician, however, should not interpret this non-reaction as a lack of patient concern or worry. In some cases, these same individuals go on to exhibit distress by other means (e.g., an increased reporting of physical symptoms, additional nonverbal communication of pain, or other behaviors aimed at gaining the attention of the treatment team). The patient might also simply be in shock and may be having a difficult time absorbing the distressing information.
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 is 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.
Simple choices in words, information depth, speech patterns, body position, and facial expression can greatly affect the quality of one-to-one communication between the patient and physician. To a large degree, these are conscious choices that can be learned and customized by the physician to fit particular patients in clinical situations. Avoiding communication pitfalls and sharpening basic communication skills can help strengthen the patient-physician bond that many patients and physicians believe is lacking.