Effective Communication in Health Care

Authors:
Darryl S. Chutka, MD
Associate Professor of Medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota

Anthony C. Berman, EdD
Assistant Professor of Education, School of Education, Hamline University, Saint Paul, Minnesota

Citation:
Chutka DS, Berman AC. Effective communication in health care [published online April 3, 2019]. Consultant360.

Despite the fact that medical knowledge and technology have both increased significantly with time, patients are often dissatisfied with the US health care system. They find it difficult to navigate the financial aspects of their health care, frequently dealing with insurance companies and pharmacy formularies, limiting which subspecialists they can see, which medications they can take, and how much of their health care will be covered by insurance. They are also frustrated by the often limited amount of time they are given to see their health care provider. Health care providers are having equal difficulty dealing with the changes in health care, as they are being required to see more patients and increasingly document their work. The electronic medical record and its associated challenges has also become standard practice for most providers. What has not changed, however, is the fact that patients still experience illness and injury, along with the associated pain and suffering, feeling of vulnerability, fear of the future, and potential limitations on lifestyle. Patients continue to need a health care provider who can address their needs; that starts with effective communication between the health care provider and the patient.

One of the most common complaints from patients is that their health care provider does not listen to them. Providers commonly complain that due to economic constraints, the time they have with the patient is becoming increasingly shorter and inadequate. This creates a dilemma for the caregiver and makes it more difficult to obtain the information needed to develop a care plan and establish the rapport needed to create a meaningful provider-patient relationship. It is now more important than ever for providers to have effective communication with their patients. Effective communication between providers and patients has been shown to improve treatment compliance, enhance mutual understanding, and improve the provider-patient relationship.^1-3 Poor communication is often the reason for complaints about physicians to regulatory organizations and has been shown to result in an increased risk of future malpractice litigation.^1,2,4

Health care providers are trained to assess illness in patients using objective measures including a medical history, physical examination, laboratory test findings, and imaging study results. It is recognized that a variety of social issues can influence illness and the symptoms patients experience. By ignoring our patients’ values and feelings, diagnoses can be missed. The social aspects of medicine need to be in harmony with the scientific components. In order for this area to be explored, it is important that patients feel a bond with their health care provider and establish a relationship of trust and understanding. They need a validation of their fears and emotions. Providers generally agree that this relationship is vital and acknowledge that this is an important component of medical practice. The establishment of a good provider-patient relationship is essential to the effective practice of clinical medicine. It is a unique relationship composed of two individuals who in many cases have not met before. Yet within a short time, the provider is granted access to very personal and intimate details of the patient’s life. Patients generally assume their provider is competent and has a good knowledge of clinical medicine. Other than board certification, there are very few ways for patients to determine a physician’s level of medical competence. It is much easier for patients to assess whether their provider is approachable, supportive, and understanding. These are the criteria they often use to judge the quality of their provider. Health care providers are now being evaluated on their communication skills in satisfaction surveys completed by patients. In some cases, these evaluations can have financial implications for the provider.

The education of a health care provider includes significantly more than acquiring competence in medical knowledge and technical expertise. Effective providers must also have excellent communication skills in order to communicate with patients, their families, and other health care professionals. The importance of teaching communication skills is now recognized and considered one of the core competency areas not only for medical students, but also for residents. Instruction in effective communication skills has become a standard part of the curriculum at the medical school and graduate school levels. It is also being addressed in the curricula for continuing medical education courses for practicing providers. Health care providers need to know the available tools that can allow them to efficiently establish rapport with their patients, as well as gather the medical information they require in order to establish a diagnosis and treatment plan.

Communications Toolbox

The medical history has two purposes: information gathering and the establishment of rapport between the provider and the patient. The traditional approach to information gathering that we have all been taught includes determining a patient’s chief concern(s) or main problem(s), followed by a history of present illness, past medical history, medication list, social history, family history, and a systems review. Although the patient rarely gives medical information in this order, this is the traditional sequence that is written in the clinical note. Providers often ask focused questions to obtain a description of each component of the medical history. This is especially likely when they feel pressured for time. This approach is considered “provider-centric.” Although commonly used, it does not give the patient the latitude to express health concerns, and it also limits the accuracy of the medical history. It is more effective to use a “patient-centric” approach. Open-ended questions should be asked such as, “Tell me about your pain,” or, “How would you describe your symptoms?” Patients should be allowed to speak uninterrupted as they describe their health problems to their provider. This approach does not take significantly more time and yields a more accurate medical history as well as satisfied patients. This approach allows patients to feel that their provider is actually interested in them and what they have to say.

Health care providers should establish an agenda for the patient’s visit, and it is important to know what the patient’s expectations are. Patients commonly have more than one reason for seeking medical care, and the first concern expressed is not always the most important to them or the most important to their well-being. This may result in the patient bringing up an issue of importance at the end of the visit, commonly resulting in inadequate time to discuss the issue or a significant delay in the interview process. A more effective approach is to establish an agenda with the use of the phrase, “What else?” Patients are asked what medical problem or problems they have. After the patient states the main problem, asking “What else?” allows the patient to bring up other health concerns. As the provider continues to ask, “What else?,” the patient’s health issues are eventually exhausted. On occasion, the patient will bring in a list of health concerns, and the provider should ask whether the patient has such a list. If so, it is important for the provider to review the list in order to help in the prioritization process. The provider has the opportunity to determine the topics for discussion during the visit. It may be determined that there is inadequate time to discuss all of the patient’s concerns, and prioritization of topics must take place. It is the provider’s responsibility to determine which items need to be discussed during the current visit and which ones are able to wait for a subsequent visit. The patient may also be part of the negotiation regarding the visit agenda. If all of the issues are to be addressed during the interview, the provider is then able to determine how much time can be devoted to each issue, resulting in a more efficient and effective medical interview.

The second purpose of the medical history is to establish rapport with the patient. Only after rapport has been established between the patient and provider will patients feel comfortable discussing sensitive areas of their health or life. In order to provide optimal medical care to patients, we need to know their philosophy regarding their life and their beliefs regarding their health. For example, it will serve no purpose if a provider establishes a correct diagnosis and effective treatment plan that includes pharmacologic therapy if the patient is strongly opposed to taking any medications. If all goes well in the medical interview, the patient establishes a sense of trust with the provider. This will lead to greater adherence to recommendations given by the provider. This is important if we are trying to encourage our patients to stop smoking, lose weight, start an exercise program, or eat correctly. Understanding a patient’s feelings and perspective is empathy. When providers demonstrate empathy, patients have greater satisfaction with them and show a greater compliance with treatment recommendations. A variety of responses help demonstrate empathy. This includes good eye contact, appropriate posture, and mannerisms of the provider. Reflective phrases such as, “Let me see if I understand what you’re telling me,” or, “I want to be sure I understand what you’re saying,” result in the patients’ realization that their provider is interested in what they are saying and feel it is important to have accurate information. It shows that the provider is actually listening to the patient and wants to understand. This technique is known as active listening. It is also wise to use reflection at the end of the patient interview on a particular topic. This represents a review of the patients’ content regarding their history. “What I hear you saying is that you developed this sharp pain just below your waist immediately after you woke up. Is that correct?” This allows the patient to make any necessary corrections in what the provider heard. Empathy also includes a recognition of the patient’s emotional response to symptoms such as, “You appear to be somewhat frightened by this,” or, “This must have been very difficult for you, and you appear somewhat sad.” At times this emotional response is obvious, but at times it may not be clear.

An effective tool that can be used to help build a relationship with patients is the mnemonic PEARLS.⁵

P represents partnership. Having one’s health or symptoms evaluated can be a frightening experience. Patients commonly have a fear that their symptoms represent a serious disease. Conveying to the patients that they are in a partnership with us and that “we are in this together” improves the interpersonal aspects of medicine. It is important to use phrases like “we” instead of “you” when discussing plans for evaluation or treatment.

E stands for empathy. To be an effective health care provider, we must show empathy toward our patients. Empathy puts our feelings into words and shows that we have an understanding with our patients. When a patient appears to demonstrate a specific emotion, it can be helpful for the provider to address that: “You look sad/frustrated/angry.” Once emotions are brought out into the open, there is often a greater sense of understanding between patient and provider.

A represents apology or acknowledgement. When a problem has occurred or an error has taken place, an apology shows concern and compassion. Comments such as, “I’m sorry you’ve had to wait,” or, “I’m sorry I ordered the wrong dose of medication for you,” can be helpful. It is also helpful when acknowledging difficult situations. “I’m sorry I don’t have better news for you,” or, “I’m sorry you are going through this difficult time.”

R stands for respect. It is important for patients to know that we respect them and their decisions, even when we feel patients have made an incorrect choice. We can still show respect for their attempts to improve their health. Comments such as, “You’ve worked very hard on this, and I respect the fact that you are trying to improve your health,” are helpful to let our patients know that we value their efforts.

L is for legitimization. This helps to acknowledge our patients’ thoughts and feelings. “Anyone would be frustrated by all you’ve been through and the fact that you’re not feeling any better.”

S stands for support. Conveying support for the patient is extremely important in health care. Patients need to know that we will be available to them in the future. This is even more important when patients are given a new diagnosis or start a new therapy. There is a sense of comfort in the knowledge that we will be available if and when the patient needs us.

Nonverbal Communication

A significant portion of a provider-patient relationship is determined not by what providers say, but rather what is communicated by their body language.⁶ Nonverbal communication affects how patients determine how well they like, respect, and trust their provider. The psychologist/sociologist James Borg estimated that “Human communication consists of 93% body language and paralinguistic clues, while only 7% of communication consists of words themselves.”⁷

There are two components to nonverbal communication: how a patient views the provider, and how the provider views the patient. Providers use nonverbal clues of our patients as part of our evaluation. It is helpful to estimate the reliability of their history, the degree of pain they are experiencing, and their emotional state. It is a valuable tool used by experienced providers as part of their patient assessment. We evaluate the amount of eye contact the patient has with us, what they are doing with their extremities, their facial expression in showing emotion, and tone of speech.

Similarly, patients assess our nonverbal communication in their impression of us as health providers, judging our thoroughness and degree of compassion. It is estimated that a patient’s first impression takes place very quickly in the provider-patient encounter. Time estimates vary, but many believe that this takes place in the initial 10 seconds of an interview. Walking briskly into an examination room can give patients an impression that their provider is in a hurry and may not have adequate time to address their concerns. The provider should be at eye level with the patient. Speaking to the patient while standing over them conveys a sense of power by the provider over the patient. Eye contact is a very important part of nonverbal communication. A variety of emotions can be conveyed by our eyes, including interest, anger, hostility, and compassion. Inadequate eye contact with the patient and an excessive time taking notes implies a disinterest in the patient. Even the distance the provider sits from the patient plays a role. Sitting too far from the patient gives an appearance of indifference, while sitting too close can make the patients feel uncomfortable and the feeling that their personal space is being invaded. Patients have indicated that when their physicians face them and lean forward slightly, they have increased satisfaction with the provider.⁸ This satisfaction decreases when the provider leans back in the chair during the interview, especially when they cross their arms and/or legs. Affirming head motions and comments are also associated with high patient satisfaction^9,10 and give patients the impression that their provider is listening to what they are saying. Appropriate light touch by the provider can promote a sense of compassion and empathy towards the patient; however, touch should be avoided if the provider is uncomfortable with it. Patients can often sense how sincere we are with touch if it is not something we do comfortably. Our tone of voice often says more than the words we say. Inflection, timing, volume, and speed of delivery can indicate anger, confidence, or compassion. A provider who smiles frequently, uses light humor, and occasionally laughs is also viewed favorably by most patients.

Giving Patients Bad or Unexpected News

Occasionally, health care providers need to give patients bad or unexpected news. This can be difficult for both the patient and the health care provider. It is more comforting to the patient when this information comes from a provider who has established a good relationship with the patient. Bad news does not necessarily mean discussing a terminal illness. Conditions which require major changes or even starting pharmacologic therapy can also be difficult for the patient to accept. One approach to use for this is the mnemonic SPIKES.¹¹

S stands for setting up. This information should take place in a proper environment. Unless absolutely necessary, it should take place in a face-to-face visit. It can be helpful for the patient to have a family member or friend for support at this visit.

P represents perception. It is important to determine how much the patients already know about the information to be shared.

I stands for invitation. The provider should ask patients if it is acceptable to share their health information with them.

K stands for knowledge. Once permission is granted by the patient, the knowledge is shared with the patient. This needs to be done in terms the patient understands.

E represents emotions. Once this information is conveyed to the patient, the patient may demonstrate a variety of emotions. Feelings of sadness, denial, frustration, or fear are commonly experienced. It is sometimes helpful for the provider to address these emotions and reassure patients that they are normal. Sometimes silence is the best approach for the provider while patients weigh the information they just received.

S is for summary or strategy. Once the patient is ready to continue, the summary or strategy for the future should be discussed. Rather than asking patients if they have any questions, it is more effective to ask, “What questions do you have?” with the expectation that the patient does have questions. The tendency is to give patients too much information, which can overwhelm them. It is also common for patients to hear very little of what the provider says immediately after they are given the bad news. Sometimes, it is best to give just the information the patient requests.

Patient Education

Conveying clinical information to our patients can be challenging. Describing medical information is very similar to speaking a foreign language. The information is often technical, and although other health care providers understand us, our patients often do not. To confuse the issue, patients’ understanding of their medical condition can be influenced by their personal fears, beliefs, and values, as well as what they have heard from others. Most patients also have access to health information contained in the press and on the internet. While much of this information can be useful, a great deal of inaccurate information also is present.

During patient education, the technique of “ask-tell-ask” can be helpful.¹² When discussing a medical issue with a patient, it is wise to determine the baseline knowledge the patient possesses. Some patients will have already researched the topic and have a fair amount of knowledge regarding their condition. Others will have no background knowledge or will have heard incorrect information. Once the baseline information regarding their condition is known, information should then be given to patients in terms that they will understand. After the information has been discussed, patients should be asked their understanding and their feelings. This is done to help ensure that the patient completely understands the information.

Electronic Medical Record

An electronic medical record (EMR) can be a major hindrance to good communication between health care providers and patients. The EMR monitor is often placed in a position directly in front of the provider. It can result in decreased eye contact between the provider and the patient and has the potential to create a distraction to communication. On the other hand, if used correctly, the EMR can play a major role in improving communication. It can enhance patient education and improve the efficiency of an office visit.

The EMR contains a wealth of information about the patient that can be quickly accessed. A medical problem list, current and recent medications, subspecialty consultations, laboratory test results, and imaging study results are all easily available to the provider. These can help with a discussion of treatment recommendations. It is recommended that the provider review the patient’s medical information on the EMR prior to entering the examination room. It is also wise to engage the patient in conversation for a few minutes prior to logging on to the EMR. The location of the monitor plays a major role in whether the EMR improves or impairs communication. It should ideally be located between the provider and the patient forming a triangle, positioned such that both are able to view the information on the screen. Previous clinical notes can be reviewed together, providing a framework for the medical interview and facilitating an update on each medical problem. Trends in laboratory test results can be easily demonstrated along with various trends from year to year. Gradual worsening of blood glucose or cholesterol readings, for example, can be eye-opening for patients when viewed over time. Sharing imaging studies allow for ease in showing patients why their knee hurts or why it is important that they continue treatment for osteoporosis.

Conclusion

Effective communication between the health care provider and the patient is extremely important, and there is evidence that health care providers have room for improvement in their communication skills. Effective communication not only improves patient satisfaction but also results in a more efficient, accurate, and thorough medical history.

There are many other proven advantages of good communication. With the use of several simple communication tools, health care providers can improve their ability to communicate with patients.