Health care providers spend the majority of their time doing on one communication with their patients. It’s well recognized that good communication skills are the cornerstone of an effective patient-provider relationship. The following tips are the elements physicians need to help them reach this goal. I’m presenting methods of communication that we have found to be helpful in interactions with our functional gastroenterology patients. These tips can be applied to communication with patients in primary care and other sub-specialties as well.
1) Listen Actively. The clinical data is obtained through an active process of listening, observing and facilitating. This is different from some social situations where a “collective monologue” occurs. Here, the one person hardly listens to the other, and rather waits for a moment to communicate their ideas. With active listening questions are constructed based on what the patient says, rather than from any personal agenda.
2) Stay Attuned to Questioning Style and Non-Verbal Messages. Often, it’s not what you say, but how you say it that makes the difference. For example methods that engage the patient in the care process include: good eye contact, affirmative nods and gestures, a partner like relationship, closer interpersonal distance and a gentle tone of voice.
3) Elicit the Patient’s “agenda”. The clinician needs to identify how the patient understands the illness from their personal and sociocultural perspective. Several questions can be routinely asked to understand the patient’s agenda: “What brought you here today?”, “What do you think you have?“, “What worries or concerns do you have?”, “What are your thoughts of what I can do to help?”.
4) Offer Empathy. Empathy means to demonstrate an understanding of the patient’s pain and distress, while maintaining an objective and observant stance. An empathic statement would be: “I can see how difficult it has been for you to manage with your symptoms” or “I can see how much this has affected your life”.
5) Validate the patient’s feelings. Patients may experience shame or embarrassment when about to disclose personally meaningful information. The clinician needs to provide an air of acceptance and seek to validate the patient’s feelings. For example, a validating statement to a patient who is feeling shamed by others who say the problem is due to stress would be: “I can see you are upset when people say this is due to stress and you know it’s real”.
6) Set realistic goals. Patients may come to the doctor with expectations for a rapid diagnosis and for a cure. However, the clinician may see this as a chronic disorder requiring ongoing management. Therefore it helps to clarify and reconcile the patient’s goals. For example, the clinician might say: “I can understand how much you want these longstanding symptoms to go away, but realistically we need to find better ways to manage them, just like arthritis or migraine headaches. If you could reduce your symptoms by 30% or 40% would that help?”.
7) Reassure. Patients often fear serious consequences of their disease and may feel helpless, vulnerable to their condition, and out of control. Reassurance occurs by: (1) identifying the patient’s worries and concerns, (2) acknowledging and validating them, and (3) responding to their specific concerns. It’s important to avoid premature or “false” reassurances (e.g., “Don’t worry, everything’s fine”) particularly before the medical evaluation is completed.
8) Negotiate. The basis for patient-centered care is that patient and physician must mutually agree on diagnostic and treatment options. The doctor should ask about the patient’s personal experience, understanding, and interests in various treatments, and then provide choices (rather than directives) that are consistent with the patient’s beliefs. Consistent with the IOM guidelines, the patient needs to make the final decision in these options.
9) Help the patient take responsibility. Many patients may respond to their illness by feeling helpless and dependent on the clinician, thus abrogating their responsibility. However, patients with chronic illness do better when they take responsibility for their care and the clinician must encourage this. As an example, rather than asking the patient: “How is your pain doing?” one might say: “How are you managing with your pain?” The former question tends to leave the responsibility for dealing with the pain with the physician, while the latter acknowledges the patient’s role. This also off sets any negative feelings by clinician’s who feel pressured to take more responsibility than needed. Another method includes offering any of the several treatment approaches with a discussion of their risks and benefits, so that the patient can make the choice.
10) Establish boundaries. For some patients, it is important to establish and maintain “boundaries” related to frequent phone calls, unexpected visits, a tendency toward lengthy visits, or unrealistic expectations for care. The clinician needs to present expectations in a way that is not perceived as rejecting or belittling to the patient yet is also consistent with personal needs. For example, if a patient calls by phone during off hours when not on call, the clinician can gently remind the patient that it would be better to have the discussion in the office or at the next visit. Here it is important not to try to address the issue on the phone as that might encourage further phone calls.
Douglas A. Drossman, MD
For additional information, please see the following article:
2012 David Sun Lecture: Helping Your Patient by Helping Yourself – How to Improve the Patient – Physician Relationship by Optimizing Communication Skills; Douglas A. Drossman, MD; Am J Gastroenterol 2013; 108:521–528; doi: 10.1038/ajg.2013.56; published online 19 March 2013.