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How effective communication promotes better health outcomes
Richard W. Seidel, PhD, LLCDr. Seidel is on the faculty of the Bayer Institute for Health Care Communication. He is Director of Clinical Programs for Carilion Behavioral Health, Assistant Professor of Clinical Psychiatric Medicine at the University of Virginia School of Medicine, and Adjunct Professor of Psychology at Virginia Tech. This article was prepared by Dr. Seidel and JAAPA editor in chief Sarah Zarbock, PA-C, and is based on Dr. Seidel's presentation at Innovations and Best Practices in Patient Adherence, an invitational meeting sponsored by the Physician Assistant Foundation and the American Academy of Physician Assistants, Washington, DC, April 20-21, 2004.Talking with patients is a procedure—the most commonly performed intervention during clinical encounters—and doing it well requires practice and experience.
The success of the clinician-patient relationship is influenced significantly by how the two parties interact with each other. The clinician is responsible not only for delivering a service, but also for delivering it in a way that facilitates the effective implementation of the treatment plan. Communication is therefore an essential component of the clinician's role; it cannot be delegated to anyone else, and it has a lasting effect over time.1 Furthermore, when health professionals and patients communicate effectively, health outcomes—including diagnostic accuracy, patient adherence, and biological measures of health such as reduced levels of pain and lowered blood pressure—are improved. Effective communication also improves the patient's understanding of informed consent, reduces malpractice risk, and improves social outcomes such as patient and clinician satisfaction. Communication, because it requires a set of skills, should be considered a procedure and is the most commonly performed intervention during clinical encounters. A typical clinician will conduct more than 160,000 interviews during a 40-year career. Effective communication—which maximizes the effectiveness of the clinician's medical knowledge and experience—can be learned, but mastery requires practice. Historically, the physician has been a discoverer and identifier of pathology and an agent of healing—an approach sometimes referred to as "find it and fix it."2 This model was and is taught in medical schools and consists of learning how to perform a long list of biomedical tasks. When applied to interactions with patients, however, the model is both too narrow and too focused on pathophysiology. A new paradigm of disease and healing has developed that encompasses psychological, sociological, and behavioral forces that are always present in both clinicians and patients. This new approach includes a focus on the medical interview and emphasizes that what occurs during the interview has an impact on outcomes. Four communication or relationship tasks must be performed during the medical encounter to ensure maximal benefit for the patient and the clinician. They require specific skills to be effective. These tasks do not replace or compete with what is needed to find and fix the medical problem. Instead, they make it possible to perform the traditional medical tasks more effectively. These tasks—engaging, empathizing, educating, and enlisting—occur on a two-way street between patient and clinician. A model of complete clinical care occurs when biomedical tasks and communication tasks are combined. In the clinician-patient relationship, each has a "voice."3 Clinicians have the voice of medicine, backed by their education, training, and experience, while patients have a voice of personal experience and ask, "What is the meaning of this in my life?" The gap between the two voices needs to be bridged before effective communication can take place. It is the clinician's responsibility to ensure that the bridge is crossed. EngagementEngagement is the connection that occurs throughout the encounter with the patient, person to person. The PA's relationship with the patient needs to be viewed as a professional partnership. This is particularly true in the United States, where so many people face chronic illnesses and therefore make multiple health care decisions every day. Clinicians have a unique vocabulary that they use to understand and solve problems. Patients, on the other hand, do not have that vocabulary, but they do have an illness experience only they understand—and they need to tell their story. It is the PA's responsibility to elicit this personal information. Several barriers can disrupt the engagement process. From a distance, an observer may have trouble distinguishing whether the patient interview is an inquiry or an inquisition. Clinicians usually have limited time available to find out what the patient has to say. As a result, their questions may sound more like an investigation than a two-way conversation. To be effective communicators, PAs should seek more of a partnership with their patients. Ask the question, "Why are you here?"—and then allow space and time to hear what the patient has to say. Take care also not to pepper the remainder of the interview with interruptions; observational research found that the average physician interrupts the patient narrative for the first time after only 18 seconds.4 This sense of being rushed increases because patients quite frequently come to their office visit with more than one complaint—and sometimes with many. Additionally, patients need to know what is happening during the encounter and to believe that their experiences and expectations are understood. Engagement is what orients patients to the process of the visit or their care. Clinicians also should convey the message to their patients that they are interested in getting the whole story—by allowing sufficient time for the patient to tell it, and by acknowledging an understanding of the patient's experience, such as, "That must have been uncomfortable." One way to encourage the patient to discuss goals or expectations of the encounter is to ask, "What were you hoping we'd accomplish today?" or "Is there anything else you were wondering about?" Open-ended questions ("I'm curious about . . .") and short summaries ("So, I hear you saying . . .") help clinicians obtain more information and validate for patients that they are being heard. EmpathyWhen the clinician is empathetic, the patient feels seen, heard, and accepted (see "Techniques that help patients feel heard"). There are several barriers to making an empathetic connection. Using the 13,000 words learned during their training, clinicians frequently speak with a vocabulary patients do not understand. Developing empathy requires that the clinician understand and articulate the feelings the patient is experiencing. For example, "It sounds like not knowing what's wrong has you very worried" conveys an understanding of the patient's experience—in contrast to "I'm sorry we don't have an answer yet for you."
Clinicians may believe that being more empathetic will take more time, yet research indicates that being empathetic actually saves time. For example, patients often provide clues about their social and emotional concerns, and when the clinician misses these clues, patients repeat them, thus requiring more time. One study found that in the primary care setting, visits with missed clues lasted 20.1 minutes, while visits without missed clues lasted 17.6 minutes. In a surgical environment, the difference was 14 minutes (missed clues) versus 12.5 minutes (without missed clues).5 EducationEducation is a complicated process that involves not just giving information, but providing it in a context that the patient can understand. Thus, education requires understanding the cognitive, emotional, and value perspectives of the patient. Educating patients provides them with greater knowledge and understanding of what is going on. It increases their capacity to deal with their illness and lowers their anxiety. The first step in educating patients is to assess their current knowledge by asking questions such as these: "What do you think is going on and why?" "What is your understanding about this illness?" "What worries you the most?" "What thoughts do you have about treatment?" This provides the clinician with baseline information about the patient's knowledge and needs. Furthermore, many patients have questions that they do not ask. Clinicians can help patients dispel "mysteries" when they answer the more difficult questions patients ask: "What has happened to me [what is the diagnosis] and why?" "What will happen to me?" "What are you going to do, and will it hurt?" Another significant challenge facing practitioners is that patients often do not understand what is being discussed, and this is not simply a matter of unfamiliar vocabulary. Forty-eight percent of adults in the United States are functionally illiterate.6 Patients with low literacy struggle to read and understand such routine health information as dosage instructions on medication bottles, poison warnings, appointment slips, and consent forms. One way for practitioners to ensure that the patient understands what is being said is to ask simple, direct questions, such as "What questions do you have?" More thorough questioning might include "Please tell me what you now understand about diabetes and how you think we need to proceed to get this under control" or "When you go home, what will you say to_______ about what we talked about today?" EnlistmentEnlistment is an invitation from the clinician to the patient to become an active collaborator in making health care decisions. The efficacy of a treatment plan depends, to a great extent, on whether the patient will adhere to a regimen. The challenge for clinicians is to understand what affects adherence and to consider these factors when communicating with patients. Adherence is related to whether patients believe in the efficacy of the treatment and are confident in their ability to carry out a prescribed regimen.7 Several questions can be asked to get a sense of the degree of conviction and confidence the patient is feeling.8 For example, the clinician can ask, "On a scale from 0 to 10, with 10 being highest, how convinced are you that you need to do this? Using the same scale, how confident are you that you can carry out this plan?" ConclusionIt is important for the PA to take an active role in enlisting the patient in the healing process.2 Communication within the clinician-patient relationship is an integral component of the role of the caregiver. A clinician who understands the value of the four "E" tasks—engagement, empathy, education, and enlistment—and uses them in concert with the traditional find-it-and-fix-it skills of medicine can offer more complete and optimal care. The result is a clinician-patient relationship that both promotes better outcomes and enhances clinician and patient satisfaction—the reasons we went into medicine in the first place!
REFERENCES 1. Makoul G. Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Acad Med. 2001;76:390-393. 2. Keller VF, Carroll JG. A new model for physician-patient communication. Patient Educ Couns. 1994;23:131-140. 3. Mishler EG. The Discourse of Medicine: Dialectics of Medical Interviews. Westport, Conn: Greenwood Publishing Group; 1985. 4. Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med. 1984;101:692-696. 5. Levinson W, Gorawara-Bhat R, Lamb J. A study of patient clues and physician responses in primary care and surgical settings. JAMA. 2000;284:1021-1027. 6. Kirsch IS, Jungeblut A, Jenkins L, Kolstad A. Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey. Washington, DC: National Center for Education Statistics, Institute of Education Sciences, US Department of Education; 1993. Available at: http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=93275 . Accessed October 6, 2004. 7. Floyd DL, Prentice-Dunn S, Rogers RW. A meta-analysis of research on protection motivation theory. J Appl Soc Psych. 2000;30:407-429. 8. Keller VF, White MK. Choices and changes: a new model for influencing patient health behaviors. J Clin Outcomes Manage. November-December 1997;4:33-36.
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