Safety of care
Physician-patient communication: Making it better
An article for physicians by physicians
Originally published December 2010
Physician-patient communication is a critical aspect of effective care that may be enhanced with these suggested approaches.
Physicians and patients would both agree on the importance of effective physician-patient communication. However, within the complex and rapidly changing health care environment, it seems that effective physician-patient communication is becoming more difficult to achieve. Changing demographics, diverse cultures, different languages, more engaged and informed patients, scarce physician resources and other factors have combined to create some challenging communication issues.
The CMPA regularly receives inquiries from members on how to improve physician-patient communication. In fact, the CMPA often assists members facing regulatory authority (College) or hospital complaints arising out of communication-related issues.
Some key communication themes are apparent from a review of the CMPA's medico-legal incident data regarding physician-patient communication (College and hospital cases from January 2009 to present). The themes highlight the importance of:
- establishing rapport with patients
- communicating clearly, honestly and directly
- listening actively
- being polite and sensitive
- checking for patient understanding of diagnosis/treatment options
- communicating in a timely manner
While these elements of good communication may seem obvious, they may be forgotten in the stress-filled, fast-paced environments in which physicians often find themselves.
This article discusses the significance of effective physician-patient communication, and provides concrete suggestions to members for enhancing this critical aspect of effective care.
In stressful situations, take a moment
To help achieve good communications in stressful situations, it is suggested that physicians take a moment before or during discussions with patients to check their own emotional vital signs. How is your pulse rate? Are your shoulders tight with tension? Are you grinding your teeth? It is important to compose yourself, recall the three Ps, and then communicate effectively with your patient.
The three Ps of effective physician-patient communication
Politeness, parity and patience can become areas of communication difficulty for physicians confronted with the new realities of health care delivery.1 However, even in tension-filled and high-stress situations, physicians are encouraged to call this trio to mind. Patients are also faced with frustrating health care concerns and irritants that can contribute to patient complaints. Polite, courteous and respectful communication will go a long way to ensuring that physicianpatient communication remains as constructive as possible, in any given situation. Parity refers to communication among equals. This includes avoiding what may be perceived as a paternalistic approach in language, tone and body positioning. Patience really is a virtue. More than ever, the work environment is challenging, shifts are long, and physicians are tired. Demonstrating patience, including tolerance and endurance, is difficult but necessary.
Related to the above is what may be known as "etiquette-based medicine."2 While patients ideally deserve to have a compassionate and empathetic doctor, most patients probably care more about whether their physician is respectful and attentive. Etiquette-based medicine comes down to good manners. Physician etiquette can include such actions as: asking permission to enter the room; introducing yourself; sitting down; briefly explaining your role; and then asking the patient about his or her condition or feelings. These actions are tied to good manners and can help form a basis for effective physician-patient communication.
Listening is one of the most important skills we can possess. How well we listen has a major impact on our job effectiveness and on the quality of relationships with others. This is also the case in regards to effective physicianpatient communication. Even if a physician makes an effort to listen actively, patient dissatisfaction can stem from a patient's impression that a physician is too busy or does not care. Linguistic or cultural misunderstandings can further complicate the situation.
It is important that physicians make reasonable attempts to listen to a patient's health concerns. Active listening requires that a physician focus on the patient and suspend his or her own frame of reference. Having listened actively, the physician will be able to check and paraphrase the patient's words. Patients will then perceive the physicain as attentive and conscientious, not distant and aloof.
Physicians should also consider periodically summarizing the information learned during a discussion with patients, particularly after a lengthy or weighty dialogue. This can help clarify information, validate understanding, and provide the opportunity to ask and answer new questions.
The link to health literacy
Many physicians find themselves caring for patients who have limited health literacy. The patient's ability to read, understand and use health care information can affect patient compliance and treatment success, and may increase the risk of adverse events if information is poorly understood. The use of plain language, "teach back" methods3 and asking patients if they have questions can enhance the effectiveness of physician-patient communication. Printed information and illustrations can also help.
Communicating difficult information
No physician enjoys dealing with bad results or giving bad news to patients, however this is sometimes unavoidable. During difficult times, patients and families often look to their physician for answers and support. Patients also want their physician to be accessible. In most cases, an honest, frank and timely discussion of the problem with the patient and the family will be helpful.
A number of different communication models are available to help physicians convey difficult information to patients. Common elements of most of these models include choosing the right setting, showing empathy, communicating facts clearly, exploring the patient's understanding of what he or she has just learned, and establishing next steps. Regardless of which model a physician prefers, having a plan of action should help considerably.4
Defusing tense situations
The basis for a good physician-patient relationship is mutual respect and understanding. A considerate attitude, recognition and acknowledgement of the patient's or family member's concerns can help resolve friction.
If a physician's communication style does not match the patient's needs, it may contribute to difficulty with understanding and frustration for all parties. Physicians should consider switching to another approach, such as describing the situation in a different way or using even less-technical language. In some circumstances, requesting assistance from a physician colleague or another health care professional may improve the therapeutic relationship. Sometimes it is best to simply end a confrontational conversation to neutralize the situation.
At times, physician-patient relationships can be very challenging. Consider cases where a discussion with an aggressive patient leads to a confrontation. The professional approach requires the physician to take steps to defuse the situation. Keeping calm and outlining the issues and offering possible solutions may help. However, health professionals should not tolerate verbal abuse and one should not put oneself or other co-workers at risk of physical injury.
Communicating about harm
Disclosure is the process by which an adverse event is communicated to the patient. Physicians and other health care providers have an ethical, professional and legal obligation to disclose adverse events. In these circumstances, patients have clinical, emotional and information needs. Patients expect to be told the facts about harm they have experienced, whatever the reason for it, and this information needs to be delivered in a caring and supportive manner. In 2008, the CMPA published a guide for its members on disclosing adverse events, entitled Disclosing harm from healthcare delivery: Open and honest communication with patients. The key elements include:
- attending to clinical care
- planning the disclosure discussions
- determining and stating the facts
- expressing regret and apologizing as appropriate
- committing to improve the system of care
CMPA members are encouraged to consult this publication, and to follow the advice on communicating with your patient if an unanticipated poor clinical outcome has occurred during care.
Physicians should talk to patients about the symptoms and signs that should prompt them to seek further medical attention. The patient should feel welcome to seek re-evaluation.
The importance of documentation
Discussions with patients should be documented in their medical record. This is important for continuity of care and provides the best evidence of the encounter. Careful documentation of specific communications with the patient and family will demonstrate clinical care and any attempts to resolve friction.
Telephone and email communication
Telephone and email communication between physicians and patients is becoming more common. Before giving telephone advice, physicians should be satisfied that they have obtained enough information to be confident the advice is appropriate. Again, proper documentation of the discussion will be important should the advice ever be called into question.
Despite the potential advantages of email communication, physicians should be aware of related risks and consider suitable protective measures. The three major areas of potential liability in email communication are confidentiality/privacy/security, timeliness of response and clarity of communication.
The CMPA recommends that physicians use a written form to document a patient's consent to subsequent email communication. The CMPA website contains a template consent form for physician-patient email communication. This template includes information about the risks of using email, conditions of using email, instructions for communication by email, as well as a section for the patient's acknowledgement and agreement (signature). Even when it is not feasible to document a patient's consent using a written consent form, physicians should still use the patient's medical record to document discussions held and any consent to email communication.
Talk to the CMPA
Any CMPA member with specific concerns about physician-patient communication should contact the CMPA for advice. Our medical officers will be able to discuss the facts of the case, and advise members on how to best deal with the situation. In these cases, we encourage members to call us at 1 800 267-6522 or submit a medico-legal assistance/web mail form.
1 Berringer, R. The Canadian Medical Protective Association. Personal communication. September 7, 2010.
2 Kahn, M. Etiquette-based medicine. N Engl J 2008;358:1988-89.
3 The teach back helps to confirm that the patient understands what has been explained or discussed. After an explanation, the patient describes the concept or plan in his/her own words.
4 Buckman, R. Breaking bad news: the SPIKES strategy. Community Oncology 2005:2:138-42.