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Patient-centred communication


Fostering understanding

Barriers to understanding


Commonly asserted by patients in lawsuits

I didn't understand...
  • what would happen
  • what to expect
  • what to do

Case: Miscommunication with a mother
Sad little girl with a fever

Background

A two-year-old child is brought to his family physician with a fever, cough, and tachypnea. After a careful history and a thorough physical examination, the physician orders a chest X-ray which confirms pneumonia. The physician, who is very rushed, prescribes an antibiotic and succinctly informs the mother to follow up in 2 to 3 days.

The mother believes the physician was not listening to her concerns and does not have confidence in his recommendations. She takes her child to see another physician the same day. The second physician independently arrives at the same diagnosis and prescribes the same antibiotic.

The child's mother  complains
College (regulatory authority) complaint:  The health professional colleges of each of the provinces or territories are the self-regulating bodies for that province's or territory's health professionals. Each college must investigate complaints from members of the public or others about health professionals who are members of the college.
(See Regulatory authority, professional)
 to the medical regulatory authority (College) that the first doctor did not listen to her concerns and, as a result, she was forced to see a second physician.

Outcome

The College reviewed the medical record created by the first physician and concluded the examination and treatment were appropriate.

The College reminded the physician that his failure to communicate effectively with the child's mother left her feeling unsure of the diagnosis and unaware of the rationale for his recommended treatment.

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Case: Impatience with a new patient
Impatient-looking female physician

Background

A 33-year-old male with a long history of drug abuse attends an appointment with a new physician. He indicates he is taking Methadone prescribed by another physician. The patient speaks despairingly about previous physicians he had consulted and indicates he wishes to stop all his medications immediately.

The physician advises him not to do this due to potential life-threatening withdrawal symptoms. She recommends that the patient follow up with his previous doctor to determine a plan to discontinue the Methadone.

The patient complains to the College that the physician was rushed, impatient, and lacked appropriate knowledge about addiction and treatment options.

Outcome

The physician admitted she was impatient with the patient but also stated she had tried to develop a working relationship to no avail.

The College dismissed the complaint but reminded the physician of the importance of patience when communicating with patients.

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Case: Cancer patient declines to sign consent form for surgery
Corner of a patient consent form

Background

An overall healthy man with a history of hemorrhoids presents to his family doctor due to streaks of blood in the stool. An investigation reveals bowel carcinoma. The patient is referred to a surgeon. Following a consent discussion for partial bowel resection, the patient refuses to sign the consent form.

Think about it

What should you do if a patient declines to sign a consent form?

Suggestions

There may be several issues to deal with:

Concerns
Despite the explanations of the risks and benefits of the proposed treatment, does the patient have unanswered questions about the surgery? Further explanations may help.

Signing a form
The refusal to sign may be related to apprehension about signing a legal form. An explanation about the reason for the form may alleviate the patient's concerns.

Suggestions continued

Barriers
If a language barrier exists, a family member may be asked to translate (with the patient's permission), or a translation service may be used. Consider whether additional supports for those with visual, hearing, or other impairments are required.

Culture
Try to be sensitive to the cultural background of your patient. Because communication styles vary across cultures, consider seeking advice from those knowledgeable in a particular culture.

Any discussions with the patient and the patient's decision should be documented in the medical record.

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Health literacy

Patients seek medical care because they have concerns. Anxieties and fears may affect the way patients think and express themselves.  Health literacy
Health literacy:  The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

Reference: U.S. Department of Health and Human Services, National Library of Medicine, Current Bibliographies in Medicine: Health Literacy, edited by R.M. Parker, S.C. Ratzan, C.R. Selden, M. Zorn, (2000).

  and the ability to understand healthcare information will vary from patient to patient and may be less than expected, potentially leading them to misinterpret information.

Non-verbal clues

Communication is more than just what is said. A patient's hesitancy, tone of voice, facial gestures, and body language can all be indicators of potential misunderstanding. A physician in tune with these clues will try to clarify the meaning. Of course, it is important to avoid using a tone or gestures that might offend the patient.

Gender

Physicians need to be aware of the potential discomfort male patients may experience with female physicians and vice versa. Carefully explain to the patient the reasons for potentially sensitive questions or physical examinations.

Cultural and language barriers

In Canada, patients and physicians come from many different cultures. It is possible to unintentionally offend by missing clues or misunderstanding a cultural viewpoint.

A patient may seem to be fluent in the doctor's language, but if it is the patient's second or third language there may be gaps in understanding. In such circumstances, it may be appropriate to use a trusted interpreter. Physicians should however be wary about using friends or family members, whose interpretation may be influenced by their own views of the discussion. For instance, a family member might be embarrassed to translate your questions about sexual activity, and the patient might be reluctant to reveal the truth.