Professional Documents
Culture Documents
Patient-physician communication is an integral part of immutable personal styles that emerge during residency but,
clinical practice. When done well, such communication instead, as a set of measurable and modifiable behaviors that
produces a therapeutic effect for the patient, as has been can evolve. Based on emerging literature on the value of
validated in controlled studies. Formal training programs effective communication, medical students and postgraduates
have been created to enhance and measure specific com- are increasingly given instruction on techniques for listening,
munication skills. Many of these efforts, however, focus on explaining, questioning, counseling, and motivating. As such
medical schools and early postgraduate years and, there- techniques are central to delivering a full and tailored health
fore, remain isolated in academic settings. Thus, the com- prescription, 65% of medical schools now teach communi-
munication skills of the busy physician often remain cations skills.5 Training in patient-physician communication
poorly developed, and the need for established physi- is also now objectively evaluated as a core competency in
cians to become better communicators continues. In this various accreditation settings, including the Comprehensive
article, the authors briefly review the why and how of Osteopathic Medical Licensing Examination—USA—Per-
effective patient-physician communication. They begin formance Evaluation, the United States Medical Licensing
by reviewing current data on the benefits of effective com- Examination, and the American Board of Medical Specialties’
munication in the clinical context of physicians caring for certification.6-8
patients. The authors then offer specific guidance on how These efforts to improve and measure communication
to achieve effective communication in the patient-physi- skills are timely, as the barriers to effective communication
cian relationship. between patients and physicians are growing (Figure 1). Despite
evidence indicating that the average length of the patient-
needed by physicians. For example, the Accreditation Council step in presenting information to a patient would be to describe
for Graduate Medical Education recommends that physicians the risks and benefits of the procedure and then to simply
become competent in five key communication skills: (1) lis- allow the patient to decide how much additional information
tening effectively; (2) eliciting information using effective ques- he or she wants.31 However, as suggested elsewhere in this sec-
tioning skills; (3) providing information using effective explana- tion, this step may require direct questions, strategic silences,
tory skills; (4) counseling and educating patients; and (5) and frequent verification that the information is actually being
making informed decisions based on patient information and comprehended.
preference.6,29 Although these and similar lists of recommended One telling sign of whether the patient is understanding
patient-physician communication strategies are valid and the information is the nature of the questions patients ask; if
useful, these tips are frequently found only in academic or questions reflect comprehension of the information just pre-
specialty journals or on the checklists now used to rate physi- sented, a further level of detail may be warranted. If ques-
cians in-training. tions reflect confusion, it is advisable that the physician return
To help practicing physicians gain and strengthen an to basic information. If the patient has no questions or is obvi-
effective and personal communication style, and, thus, improve ously uncomfortable, this is a good opportunity for the physi-
patient-physician communication and rapport, we have assem- cian to stop the discussion, ask explicitly how much informa-
bled our own list of practical steps. We hope that these tips, tion the patient desires, and adjust accordingly. Continuing to
based on our years of clinical experience and our reading of the provide further information is not always the best approach.
recent literature on patient-physician communication, will
remind colleagues that they are more than a passive conduit 3. Be Empathic
of medical information for their patients; they are interpreters Empathy is a basic skill physicians should develop to help
and shapers of their patients’ health and full partners in their them recognize the indirectly expressed emotions of their
patient’s long-term health status. patients. Once recognized, these emotions need to be acknowl-
edged and further explored during the patient-physician
1. Assess What the Patient Already Knows encounter. Further, physicians should not ignore or minimize
Before providing information, find out what a patient already patient feelings with a redirected line of inquiry relentlessly
knows about his or her condition. Many times, other physicians focused on “real” symptoms. Patient satisfaction is likely to be
or health care providers have already communicated infor- enhanced by physicians who acknowledge patients’ expressed
mation to the patient, which can have the effect of coloring emotions. Physicians who do this are less likely to be viewed
patient perceptions and perhaps even causing confusion when as uncaring by their patients.32
new information is introduced. For instance, a nephrologist
may talk about the patient “getting better” based on improving 4. Slow Down
renal function tests, while a cardiologist is focused on the Physicians who provide information in a slow and deliberate
patient’s severe, irreversible cardiomyopathy. In other sce- fashion allow the time needed for patients to comprehend the
narios, patients will come to the physician with preconceived new information. Other techniques physicians can use to allow
notions about a particular condition, perhaps based on less- time include pausing frequently and reinforcing silence with
than-authoritative sources. It is important, therefore, to deter- appropriate body language. A slow delivery with appropriate
mine what a patient already understands—or misunder- pauses also gives the listener time to formulate questions,
stands—at the outset. which the physician can then use to provide further bits of tar-
geted information. Thus, a dialogue punctuated with pauses
2. Assess What the Patient Wants to Know leads to deeper comprehension on both sides.
Not all patients with the same diagnosis want the same level One study found that physicians typically wait only 23 sec-
of detail in the information offered about their condition or onds after a patient begins describing his chief complain before
treatment. Studies have categorized patients on a continuum interrupting and redirecting the discussion. Such premature
of information-seeking behavior, from those who want very redirection can lead to late-arising concerns and missed oppor-
little information to those who want every detail the physician tunities to gather important data.33
can offer.30 Thus, physicians should assess whether the patient As a side note, patient satisfaction is also greater when the
desires, or will be able to comprehend, additional informa- length of the office visit matches his or her previsit expectation.34
tion. For the physician without advance knowledge of the In situations involving the delivery of bad news, the tech-
patient, this level of need will emerge by degrees as the dis- nique of simply stating the news and pausing can be particu-
cussion unfolds and as the physician attempts to synthesize and larly helpful in ensuring that the patient and patient’s family
present information in a clear and understandable manner. fully receive and understand the information. Allowing this
As when obtaining informed consent, a standard first time for silence, tears, and questions can be essential.19,20
5. Keep it Simple For both physician and patient, images of body language
Physicians should avoid engaging in long monologues in front and facial expressions will likely be remembered longer after
of the patient. Far better for the physician to keep to short the encounter than any memory of spoken words.
statements and clear, simple explanations. Those who tailor It is also important to recognize that the patient-physician
information to the patient’s desired level of information will encounter involves a two-way exchange of nonverbal infor-
improve comprehension and limit emotional distress.35 Again, mation. Patients’ facial expressions are often good indicators
physicians should be sure to ask whether patients have any of sadness, worry, or anxiety. The physician who responds
questions so that understanding can be checked and dialogue with appropriate concern to these nonverbal cues will likely
promoted. It is wise for the physician to avoid the use of jargon impact the patient’s illness to a greater degree than the physi-
whenever possible, particularly with elderly patients. cian wanting to strictly convey factual information. At the
An important fact for physicians to keep in mind is that, very least, the attentive physician will have a more satisfied
in the United States, between 20% and 40% of individuals patient.
between 60 and 80 years of age have not attained a high school Conversely, the physician’s body language and facial
diploma.36 In patients of all ages, a physician cannot assume expression also speak volumes to the patient. The physician
the understanding of treatment risks that are described with who hurriedly enters the examination room several minutes
percentages or numbers. Such “low numeracy skills” of patients late, takes furious notes, and turns away while the patient is
require that physicians take special care in outlining the rela- talking, almost certainly conveys impatience and minimal
tive risks of diagnostic procedures and treatments.37 interest in the patient. Over several such encounters, the patient
may interpret such nonverbal behavior as a message that his
6. Tell the Truth or her visit is unimportant, despite any spoken assurances to
It is important to be truthful. In addition, it is important that the contrary. Thus, it is imperative that the physician be aware
physicians not minimize the impact of what they are saying. of his or her own implicit messages, as well as recognizing the
For example, euphemisms may soften the delivery of sad nonverbal cues of the patient.
information but can be extremely misleading and create con-
fusion. 9. Be Prepared for a Reaction
Saying that a patient has “gone” or has “left us,” for Patients vary, not only in their willingness and ability to absorb
example, could be interpreted by an anxious family member information, but in their reactions to physician communications.
as meaning that the patient has left his room to have a radio- Most physicians quickly develop a sense for the various coping
logic film taken or to undergo a test. Alternatively, physicians styles of patients, a range of human reactions that has been
who use “D” words (eg, dying, died, dead), when appro- categorized in several specific clinical settings.40
priate, effectively communicate the circumstance and mini- For instance, a certain percentage of individuals will meet
mize confusion.38 almost any bad medical news in a nonemotional, stoic manner.
7. Be Hopeful
Although the need for truth-telling remains primary, the ther-
apeutic value of conveying hope in situations that may appear Checklist
hopeless should not be underestimated. Particularly in the
context of terminal illness and end-of-life care, hope should not
be discouraged. Using highly technical language or jargon when
For example, in situations such as the imminent death of communicating with the patient
a patient, hope can be conveyed to the family by assuring Not showing appropriate concern for problems
them that therapy can be effective in allaying pain and dis- voiced by the patient
comfort. Thus, even when physicians must convey a grim Not pausing to listen to the patient
prognosis to a patient or must discuss the same with family Not verifying that the patient has understood the
members, being able to promise comfort and minimal suf- information presented
fering has real value.39 Using an impersonal approach or displaying any
degree of apathy in communications
8. Watch the Patient’s Body and Face Not becoming sufficiently available to the patient
Much of what is conveyed between a physician and patient
in a clinical encounter occurs through nonverbal communi-
cation.
Figure 2. Communication traps to avoid.
12. Betancourt JR, Green AR, Carrillo JE, Ananeh-Firempong O 2nd. Defining
Conclusion cultural competence: a practical framework for addressing racial/ethnic dis-
Simple choices in words, information depth, speech patterns, parities in health and health care. Public Health Rep. 2003;118(4):293-302.
body position, and facial expression can greatly affect the
13. Kundhal KK, Kundhal PS. MSJAMA. Cultural diversity: an evolving chal-
quality of one-to-one communication between the patient and lenge to physician-patient communication. JAMA. 2003;289(1):94.
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cian-patient relationship. Alaska Med. 2002;44(4):75-82.
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