By Kathleen Daily Mock, BSN, JD
Communication matters. It’s not rocket science, yet it is a concept routinely ignored in the education of clinicians. Patients know that communication matters, and it is often poor communication in the face of a bad outcome that initiates legal action by the patient turned plaintiff.
Ineffective communication often reduces the accuracy of a clinician’s diagnosis. Indeed, research shows that clinicians allow the patient only 18 seconds to present the story of their illness before interrupting. Additionally, the same research shows that only two percent of those patients ever get the opportunity to complete their story. By cutting off the flow of information from the patient, the clinician is often deprived of facts that are likely germane to a correct diagnosis. Numerous studies also indicate that communication between clinician and patient is the single most effective predictor of patient adherence to a treatment plan. If the clinician utilizes effective communication skills, the patient will become an educated participant in the treatment, thereby increasing the likelihood of compliance. Add to this mix the increased pressure from the insurance industry to shorten patient visits, and good communication skills become an essential element of the clinician-patient relationship.
The concept of effective clinician-patient communication is a necessity, not an option. Because communication is both a science and an art that can be learned and mastered, there are many resulting benefits for those who work diligently to improve their technique, not the least of which is increased clinician satisfaction.
According to the Bayer Institute for Health Care Communication, a clinician’s role in communicating effectively with patients can be broken down into a process that includes the following communication tasks: engagement, empathy, education and enlistment.
Engagement is a connection between the clinician and patient that continues throughout the encounter and sets the stage for the establishment of a partnership. Barriers to engagement by the clinician include the failure to introduce oneself, inquisition-type questioning, and interruption of the patient’s story.
Techniques for successful engagement include showing interest in the patient as a person, eliciting the patient’s agenda and expectations up front(perhaps at the expense of your own agenda), negotiating and prioritizing the agenda for the visit, and using the patient’s language rather than medical jargon.
Remember the expression, “You don’t get a second chance to make a first impression.” Be cognizant that both your actions and your words express your interest in the patient as well as the medical problems they bring to the table.
The outcomes of successful engagement are rewarding. For example, the quantity and quality of the diagnostic information available will improve. The groundwork for a successful relationship will have been laid. Additionally, the patient will have a sense of partnership with the clinician, which will facilitate adherence to a treatment regimen.
Empathy is sincere—and successful—when a patient acknowledges that he or she has been seen, heard, and accepted as a person. This seems like a simple concept, yet the effective use of empathy presents common dilemmas for clinicians. Once again, clinicians tend to fall back on “comfortable” medical language that creates a barrier to empathy. Additionally, clinicians often confuse sympathy with empathy. What’s more, although research proves it to be untrue, some clinicians may feel that empathizing with a patient will require more time than they have to give.
Techniques that allow the clinician to exhibit empathy are varied. Initially, new patients should be seen fully clothed and proper introductions made. Creative clinicians find ways to accomplish this without adding time to the visit. For example, introductions could be made to the fully clothed patient in the waiting room. Once inside an examination room, patients should be seen on roughly the same line of sight. Be mindful of physical barriers. Desks, charts, and poor eye contact have been proven to impede empathy.
To effectively hear a patient, invite him or her to share thoughts and feelings and then affirm them by using the patient’s own words. Hearing also means allowing the patient to correct your understanding of what was said to ensure agreement.
Acceptance requires acknowledging the patient’s thoughts and feeling while reserving judgment. It also allows for self-disclosure, when appropriate. Don’t tell your life story, but do share anecdotes that will facilitate the clinician-patient bond. Keep in mind that by encouraging “windows of opportunity” through the use of open-ended questions, you’ll be better prepared to address the psychological and social, as well as medical, needs of the patient.
Education has taken place when the cognitive, behavioral, and effective needs of the patient are addressed. Research shows that clinicians overestimate the time spent in the education of their patients by nine times! In reality, approximately one minute is actually spent on this crucially important task. Poor education of patients is clearly a product of poor communication skills on the part of the clinician.
To effectively communicate, first assess what the patient already knows and then ask questions to determine what he or she might be wondering. Not all patients will be forthcoming with questions, so be prepared to probe empathetically to discover their most basic concerns and fears. Educating a patient involves providing increased knowledge and understanding while at the same time, decreasing uncertainty and anxiety.
There are several techniques to assist clinicians with patient education. Assess the patient’s current knowledge by asking about their understanding of the disease process, and ask the extremely effective question, “What do you think is going on?” Clinicians are often surprised by the valuable information this question elicits from the patient.
Always assume that all patients have the same questions, whether or not they ask them. These include:
• What has happened to me?
• Why has this happened to me?
• What will be done to me?
• Why will they do this rather than that?
• Will it hurt?
• When will you have the answers (test results)?
• When will I have the results?
Remember that education has not taken place until the patient has learned something. Be sure that all questions have been answered. Then ask how the patient understands, not if the patient understands. Also, consider that health terms may have both a clinical and lay meaning. Be clear in describing or defining terms to avoid confusion, making sure that you and the patient are on the same page.
Successful education brings great rewards. The relationship between the patient and the clinician is enhanced and the patient becomes part of the process. The patient will know and understand what is happening, what to expect, and therefore, will be less anxious. You will not bear total and sole responsibility for the implementation of the proposed regimen, and both of you will be partners in a successful treatment plan, creating a high level of mutual satisfaction.
Enlistment is an invitation by the clinician to the patient to collaborate in decision-making regarding the problem and the treatment plan.
It is a challenge to the health care provider to create a plan of treatment that the patient will accept and to which he or she will adhere. As all practitioners know, patient non-adherence is a tremendous problem. Research shows that several things affect adherence: patient’s perception of the illness, efficacy of treatment, and duration of treatment. What is clearly presented is that the relationship between the clinician and the patient is a critical factor in patient adherence.
Before they even enter the clinician’s office, most patients have made their own diagnosis—a diagnosis that more often than not, they are looking to confirm. Enlistment requires that a clinician and patient come to an agreement about the problem and prescribed treatment. To ensure collaboration, provide a “possible explanation” and ask how it fits with what the patient has been thinking. Differences in diagnoses need to be reconciled or the patient is likely to follow his or her own.
When enlisting agreement, lay out all the variables for the patient in a simple format, including such things as dosage requirements, description of benefits, and review of possible side effects. Ask for feedback to ensure true collaboration and be prepared to tailor the course of treatment based on the individual’s lifestyle, habits and routines. Flexibility is critical to arriving at a plan of action that will best suit the patient’s needs and overall health. At the completion of the visit, be sure to close effectively by summarizing the agreed-upon plan and discussing next steps.
Creating a Win-Win Situation
Although patient communication is the most common and easiest-to-improve medical procedure, its significance is often overlooked. Effective communication is key to adopting a patient-centric approach to providing medical care, and to the reduction of adversarial clinician-patient relationships. By incorporating effective communication techniques into daily patient interactions, clinicians can decrease their malpractice risk. More importantly, clinicians can positively and effectively impact patient health outcomes without increasing the length of visit—a win-win situation for both parties, and indeed the goal of health care.
Kathleen Daily Mock, BSN, JD, is founder of HCC Consultants, a Warminster, PA-based specialty consultancy that focuses on the unique and underserved communication needs of the health care industry.