Communication Skills in Clinical Practice (Doctor-Patient Communication) KR Sethuraman KR
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1Core Skills2

Doctor-Patient Communication: An Overview1

It is a distinct Art to talk Medicine in the language of non-medical man
— EH Goodman
Paradoxically, at a time of Internet-based global communication and “Cyber-medicine,” we are faced with a breakdown in communication between patients and doctors. Increasing patient dissatisfaction, rising numbers of complaints and claims for malpractice and abandonment of conventional medicine for unproven alternatives are the major problems today. In a nationwide household telephonic survey in US, physicians were rated lowest on communication skills and on attention to the costs. A similar survey of physicians showed that they too rated their training the lowest in these same areas. It is apparent that public need for adequate information is not fully met by the doctors.
 
 
 
What do Patients Want?
Most instances of patient dissatisfaction with doctors relate to problems of com-munication rather than clinical competence. The most common complaint is, “Doctors do not listen to me.” Patients want quality information about their problems and the outlook, more openness about risks of treatment, relief of pain and emotional distress, and professional guidance on what they can do for themselves.
 
Why is there a Communication Gap?
It is well-documented that doctors and patients have different views on what makes good and effective communication; the patients focus on their life-world while the doctor, on the medical-world. These differences influence the quality of doctor-patient dyad, patient education, compliance and health outcomes.
 
Why should Doctors Change?
Today, the responsibility for an individual's health care has shifted. Patients today are “health consumers” and want to be active participants in medical decision making. Studies by Kaplan et al have shown that patients tended to leave doctors who failed to involve them in decisions. Many doctors wish to 4increase their income by increasing their practice load, with a corresponding decrease in time spent per patient. This may backfire if patients abandon the ever-busy and uncaring doctor.
 
Does Quality Communication Improve Health?
Studies have documented a correlation between effective communication and improved health outcome. The outcomes affected were emotional health, resolution of symptoms, pain control, improvement in function, and even in physiological measures such as blood pressure and blood sugar levels (see Hawthorne effect).
 
Can we Learn New Communication Skills?
Firstly, with proper motivation, it is not difficult to acquire communication skills. Secondly, health care is still based on fiduciary relationship that is fostered by sharing of ideas and feelings. Thirdly, effective communication is an interactive process to elicit patient expectations and to counsel them if their expectations are unrealistic.
One should realise that communication is not merely a set of skills, and commu-nicating well is not just a matter of learning discrete pieces of surface behaviour. It is an observable manifestation of appropriate attitude, which may be much more difficult to convey and acquire. It requires development of appropriate attitude as well as cultivation of relevant skills.
 
UNDERSTANDING COMMUNICATION
Communication is derived from the Latin word communis, which means common, or general. That is what we attempt to do when we communicate: we try to find something in common (to share) between the other person(s) and us. Communication is a dynamic, ongoing, everchanging process.
 
The Process of Communication
 
Transfer and Sharing of Meanings
Communication involves transfer and sharing of meanings. Meanings may be ideas, images or thoughts expressed in symbols (e.g. writing, speech, music, clothes, smoke, artworks, etc.). It is important to realise that messages are not inherent in symbols used. Words, or whatever symbols we use to transmit our messages, have no meanings in themselves. The people involved in the communication process give meaning to these.
 
Perception
This is another essential component in the process. Perception is defined as the process of forming impressions about something (a person, an event, or any stimulus that has an effect on our consciousness), and then making a judgement about this. True communication is not possible without perception. Our perceptions and our judgement are affected/influenced by our senses (i.e. sight, sound, touch, smell and taste).5
 
The Components of Communication
 
Source/Sender
Source is where a message originates. In a clinical dyad, a doctor and a patient alternate as the source.
 
Receiver
Receiver refers to a person who receives and interprets a message being transmitted from a sender.
 
Channel
Channel is the means by which a message is transmitted from a source to a receiver. In this case, the means used are interpersonal channels, those involving face-to-face exchange.
 
Message
Message is the idea that is communicated. The sender selects and organises messages that would be most suited to a particular target audience. The message may be a piece of information, support, encouragement, motivation, correction of errors or an inquiry into something.
 
Effects
The purpose of communication is to achieve certain desired results or effects. Effects are changes that occur in a receiver because of transmission of a message. The three main types of effects are:
  • Changes in receiver's knowledge
  • Changes in receiver's attitude
  • Changes in receiver's actions.
 
Feedback in Communication
Feedback refers to the response or reaction given by the receiver to the sender about her/his ideas and actions. Feedback helps to increase or improve mutual understanding. Both positive and negative feedback should be given when appropriate. Positive feedback is given to encourage or reinforce appropriate ideas or actions. Negative feedback helps to clarify a situation, and make the sender aware of how it is perceived by others, reflect on her/his thoughts and actions, and choose to improve or change it.
 
UNDERSTANDING DOCTOR-PATIENT COMMUNICATION
Since the 70's, attention has shifted from the biomedical side to the humanistic side of medical practice. Eclectic views amalgamate both as a continuous spectrum of biopsychosocial model of medicine (Table 1.1). Depending on the context, the “Voice of Medicine” has to address the appropriate level in the hierarchy. For instance, talking to a patient about molecular basis of type 1 diabetes mellitus (DM) may 6be irrelevant if s/he is too poor to buy insulin. Inappropriate focus of the voice of medicine in an individual case is perhaps the most common cause of communication failure between patients and professionals.
Table 1.1   Hierarchy of biopsychosocial system. The upper panel is influenced by social, cultural, economic and environmental factors and the lower panel by aetiological factors of genetic and acquired diseases
World
Nation
Race/Ethnicity
Community
Family
Individual
Organ systems
Organ
Tissue
Cell
Organelle
Molecule
Atom
Subatom
 
System Analysis of Doctor-Patient Communication
A system has three functional stages of input, process and output/outcome. A clinical dyad can also be conceptualised as a system. Table 1.2 highlights the functional stages of a clinical dyad. It helps one to analyse a dyad more meaningfully.
Table 1.2   Clinical dyad as a system
Input variables
Dyadic process
Patient outcome
Disease characteristics
Cultural background
Type of patient personality
Type of doctor personality
Doctor-patient rapport
Instrumental behaviour-(Problem-solving)
Affective behaviour-(Emotional support)
Privacy behaviour
Short term: satisfaction, compliance, recall, denial, understanding, arousal of hope etc.
Long term: health status, psychological reaction.
 
Doctor-Patient Interaction Analysis (Behaviour and Privacy)
The interaction in a dyad consists of three component behaviours
  • Instrumental behaviour, which is task focussed and cure oriented. This reflects the patient's need to know, understand and cope with the illness.
  • Affective behaviour, which is social and emotional in nature, it is care oriented. It reflects the patient's need to feel known and understood as a unique human being (see “non-person”).
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  • Privacy behaviour in a dyadic analysis refers to the process of exclusion of others from the dyad. Patients—especially females—may feel the need for four types of privacy. These are:
    1. Physical privacy concerns the extent to which a patient can control physical accessibility to others, e.g. patients in general wards of teaching hospitals.
    2. Psychological privacy, refers to the patient's ability to control the interview and influence how much of and to whom personal information is given.
    3. Informational privacy is to do with confidentiality of patient information, case details and medical records, e.g. psychiatry, surgery, infectious diseases etc.
    4. Social privacy refers to control of social contacts in order to maintain status division, e.g. patients from “high society“ tend to avoid interactions with junior doctors and may expect only the senior most professional to attend to them. They may also want an exclusive waiting space to avoid mingling with the commoners.
 
Patients as Non-Persons
In many clinical settings, the patients are often considered as “non-persons”.
  • Non-persons have no name, they are known by their diseases or bed numbers.
  • Non-persons' feelings and opinions do not count. Non-persons are excluded in clinical discussions, even in those that involve risk and treatment preferences. Common examples are bedside discussions about a patient between a surgeon and an anaesthetist, among doctors or between a doctor and a nurse. In fact, if the patient concerned tries to communicate with the professionals, s/he is looked down upon as an “interfering patient”.
  • Non-persons are objects to be dealt with. They do not qualify for “privacy” (see above). It is all right to intrude into their space—at your convenience—to probe, palpate and do procedures on them. A common example is the de-humanising that is done in most intensive care units.
If you wish to really practise “patient-centred” medicine, you have to change your mindset and treat the patients as persons (human beings) with individual feelings, ideas and opinions.
 
Information Needs During a Dyad
Doctors' information needs in a dyad are two:
  1. To establish diagnosis.
  2. To plan management.
Patients' needs are also two:
  1. To know and understand the origin of symptoms.
  2. To feel known (acceptance of the patient as a ‘person’ by the doctor) and under-stood by the doctor (the patient's symptoms taken seriously by the doctor). Feeling known and understood are the missing links in many clinical dyads.
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Approach to Doctor-Patient Dyad
Physician-centred approach is one in which the doctor leads the dyad in explaining the disease and its treatment (“voice of medicine”). Patient centred approach is one in which the patient leads the dyad concerning the areas of her/his expertise, viz. symptoms, disability, treatment preferences and concerns regarding illness (“voice of lifeworld”). The latter approach needs appropriate physician responses, which enables patients to express all their reasons (“agendas”) for consulting the doctor, including their symptoms, thoughts, feelings and expectations. An ideal medical interview combines both approaches.
 
Attributes of Effective Communication (“Voice of Medicine”)
  • Accuracy Valid content presented accurately.
  • Availability The message is available to the end user at the time of its need.
  • Timeliness The message is conveyed when the audience is in need of and most receptive to it.
  • Understandable Follows the norms of clarity, choice of words appropriate for the patient.
  • Culturally competent The message, the medium and the mode of delivery are appropriate for the culture of the target group.
  • Reliability The patient feels s/he can rely on the source, and the message.
  • Evidence based The message as well as the communication method is evidence based.
  • Balance Presentation is balanced, e.g. felt need vs real need, benefit and risk, cost and benefit, natural history and outlook after intervention, etc.
  • Consistency The message is internally consistent over time and externally consistent with other sources of unbiased information.
  • Repetition Repeated delivery to reinforce the message.
 
Factors Influencing a Dyad
One should realise that in addition to the professional attributes listed above, other factors influence the process and outcome of a dyad. Major factors are—
  • Patient attributes like personality, literacy and sociocultural placement, etc.
  • Professional attributes like personality (friendly, unfriendly) and concern (concerned, not concerned)
  • Doctor-patient relationship (clinical, therapeutic, personal or intimate)
  • Severity and type of disease
  • Patient expectation and agenda
  • Type of treatment (invasive or not, level of risks, cost, etc.)
  • Time available for dyad.
 
Categories of Doctor-Patient Misunderstanding
Misunderstanding leads to most of the litigation. Awareness of common reasons for doctor-patient misunderstanding may help one to nip the problem in the bud.9
  • Patient information unknown to doctor
  • Doctor information unknown to patient
  • Conflicting information given (verbal/non-verbal mismatch, doctor to doctor variations)
  • Disagreement about attribution of causation or nature of illness (knowledge gap)
  • Failure of communication about doctor's decision
  • Relationship factors (dysfunctional dyad).
 
Language in Dyads
Doctors are bilingual—they use medical language (ML) that is technically correct and, everyday language (EL) that is easily understood by patients. Experienced doctors often switch between ML and EL in order to communicate better with their patients.
Patients may also try to use ML rather than EL. Quite often this leads to confusion. Studies have shown that a majority (64%) of patients misunderstands common health terms. “Allergy“ for a lay person in India often means things s/he detests or finds unsuitable for any reason. “Tension“ is similarly used for any kind of stress, anger or irritation. “Gastric“or “gas“ may mean eructation, indigestion, flatulence, reflux, etc. So, it is prudent for a doctor to verify what exactly the patient means whenever s/he uses medical terms.
 
Closure of a Dyad
Physicians need to improve their communication skills in the closing phase of the medical interview. In a study by White et al, the communication between physicians and patients in the closing phase of the dyad was analysed. The physicians initiated the closing in 86 percent of the visits. They clarified the plan of care in 75 percent of the visits. They asked whether the patients had more questions only in 25 percent of the cases. New problems during closure were associated with less information exchange between physicians and patients, fewer orientation statements by physicians and long closures (> 2 minutes). In 21 percent of the cases, the patients raised new problems at the end of the consultation. Orienting the patients to the flow of the consultation, assessing their beliefs, checking for understanding, and addressing psychosocial issues earlier may decrease the number of new problems introduced by them in the final moments of the visit.
 
Patient Outcome in a Dyad
Outcome is defined as an observable consequence that occurs after a dyad—or a part of the dyad—is completed. There are several components of patient outcome—knowledge and understanding of the illness, coping with illness, quality of life, psychological reaction like anxiety and depression, satisfaction, compliance, recovery, sick-role, and social support, etc.10
Physician behaviour, if supportive, may result in reinforcing the patient's self-confidence, motivation and a positive view of health resulting in a feeling of medico-social support. Such patients may even consult the same physician repeatedly for social support rather than medical treatment. A doctor who is unaware of this may wonder why such patients bother them repeatedly with minor ailments. Experienced physicians have a collection of “elderly well,“ who consult them every now and then for social support and soothe-saying rather than medical treatment (see ‘Hawthorne effect’).
 
Good Doctor-Patient Relationship
Being multifaceted and multidimensional, doctor-patient relationship is one of the most complex social relationships. It is difficult to define this complex relationship.
According to many studies, the necessary ingredients for goodness are:
  • Mutual trust
  • Honesty, and devotion to patient-care.
  • Social orientation
  • Non-judgemental attitude
  • Friendliness and empathy
  • Conveying interest and a desire to help
  • Giving patients compliments
  • Making inoffensive personal remarks, laughing or making jokes.
Carl Rogers' client-centred model comprising empathy, respect, warmth, genuineness and unconditional acceptance also indicates components of good doctor-patient relation-ship.
 
Concept of Empathy
Empathy is “feeling with” the patient, while sympathy is “feeling for” the patient. Empathy is a cerebral response, while sympathy is a visceral response.
Empathic relationship consists of
  • Eliciting patient's feelings
  • Paraphrasing and reflecting on what the patient has said
  • Using silent pauses appropriately (for reflection and introspection)
  • Listening to what the patient says and also what s/he is trying to say or is unable to say (to read between lines and beyond lines)
  • Encouragement
  • Non-verbal behaviour that complements the above.
 
SUMMARY
This chapter is meant as an overview of the doctor-patient communication pro-cess. The details of different aspects of the dyadic process follow in subsequent chapters.11
BIBLIOGRAPHY
  1. Francis PHN et al: Gaps in doctor-patient communication. New Eng J Med 280:535–40,1969.
  1. Kaplan SH, Greenfield S, Gandek B et al: Characteristics of physicians with participatory decision-making styles. Ann Intern Med 124:497–504,1996.
  1. McBride CA, Shugars DA, DiMatteo MR et al: The physician's role—views of the public and the profession on seven aspects of patient care. Arch Family Med 3(11):948–53,1994.
  1. Ong LML et al: Doctor-Patient communication—a review of literature. Soc Sci Med 40:903–18,1995.
  1. Siegfried Meryn: Improving doctor-patient communication not an option, but a necessity (Editorial). BMJ 316:1922–30,1998.
  1. White J, Levinson W, Roter D: “Oh, by the way …”: the closing moments of the medical visit. J General Intern Med 9(1): 24–28,1994.
 
EXERCISES
 
 
Group Discussion Following Video-triggers
Video triggers—from movies like “Anand”(Hindi), “The Citadel”, “Patch Adams” etc.—highlighting various aspects of doctor-patient dyad have to be collected. Each trigger—not more than 3 to 5 minutes long—will be followed by group discussion on its message.
 
Case Studies on Life-world
Using the multi-dimensional model of health care as a guide, each pair of students will talk with an in-patient to identify various social, cultural, environmental and economic factors that influence health-seeking behaviour in each instance (See annexe-2 for the model).