Doctor-Patient Communication, a 'Thorny’ Challenge

Many veteran doctors have probably been there:  You sit your patient down and explain their diagnosis. You walk them through how to take their medication. They nod and promise that they don't have any questions.

Next visit, you find out they haven't been taking those meds. And they're maybe not so sure what disease they've been diagnosed with.

Communicating - really communicating - is a thorny challenge, made worse by the pressures of the modern medical system. And lack of communication between doctors and patients is a serious problem. A 1999 study published in JAMA analyzed 199 patient interviews by family physicians and found that doctors interrupted their patients before they finished explaining their concerns after only 23.1 seconds, on average. The interruptions weren't a time-saver: Patients allowed to complete their thoughts only took six seconds longer, on average, than those who were interrupted.

Other studies suggest that patients too often leave the doctor's office without all of the information they need to manage their condition. One paper published in the Journal of Rheumatology in September 2015 surveyed 311 rheumatoid arthritis patients in southwestern Ontario and found that depending on which scale was used, only between 14 percent and 18 percent of the patients were health literate, meaning that without a lot of guidance from doctors and nurses, they were unlikely to be able to make effective healthcare decisions. Meanwhile, a 2013 study on elderly hospitalized patients at the Yale-New Haven Hospital in Connecticut found that about 40 percent had no idea of their own diagnosis.

Misunderstandings about diagnoses or medications can lead to treatment nonadherence, but poor communication between doctors and patients might also have direct effects on health. In a study published in September 2014 in the American Journal of Medicine, researchers interviewed five women with chronic pain and four healthcare providers at a clinic and found that poor communication cut both ways: Patients reported feeling dismissed, while doctors felt criticized and attacked. Patients felt angry and hopeless, which can exacerbate symptoms of pain, depression and anxiety already associated with chronic conditions, said study author Paul Dieppe, an emeritus professor of health and well-being at the University of Exeter.

"If you feel understood, life is better," Dieppe said. "In non-medical speak, it's the old wife's tale that a problem shared is a problem halved."

It's safe to say that doctors aren't waltzing into work each morning hoping to leave their patients confused and depressed. But the situation in many practices conspires against the most well-meaning of physicians: Doctors have mere minutes with their patients, patients who are reluctant to burden their doctors with financial or personal problems. Rheumatologists, in particular, are in serious shortage in many areas. And electronic medical records initiatives are killing off eye contact.

Technology is Wrecking Patient-Doctor Communication

(Continued on next page.)

Techn(ology is Wrecking Patient-Doctor Communication

Technology is "really wrecking" communication, said Iris Zink, a rheumatology nurse practitioner in Lansing, Michigan. "It's horrible."

An op-ed in JAMA in 2012 illustrates the problem, quite literally. The journal reprinted a picture drawn by a 7-year-old showing a smiling family at the doctor's office, with a likewise smiling doctor - typing away busily on his computer, back to his patient.  

"From my perspective of 20 years practicing and teaching primary care pediatrics and internal medicine and more than two years into juggling the needs of patients with those of the computer, this child's drawing powerfully expressed the deep frustration and concern of many physicians, including me," wrote Elizabeth Toll of the Warren Alpert Medical School of Brown University, in the op-ed accompanying the picture.

So what's the solution? Patient-Centric Care

The first step is figuring out what patients need. Research suggests that a feeling of collaboration with their doctor is important. A qualitative study published in March in the Journal BMC Musculoskeletal Disorders found that rheumatology patients wanted to take an active role in their care - keeping diaries of symptoms, for example, and seeing a doctor willing to discuss changes in treatment at the patient's request. Patients also valued doctors who understood the social and emotional consequences of the disease.

Coping with emotions is a key part of communications breakdown, said Zink (who was not involved in this study).

Zink finds that for patients with rheumatoid arthritis, their mind is usually somewhere else consumed with worry. In this frame of mind, patients aren't hearing their doctor's explanations of treatment options, she said. "They’re still processing, 'I have a chronic illness.'"

Another theme that emerged in the qualitative interviews was the importance of open, non-didactic communication. There's a limit to this, Zink said. Some doctors try asking their patients to research drug options on their own in an attempt to draw them into the decision-making process. That often backfires, she said, because patients do want to hear the expertise of doctors and nurses.

Training Doesn’t Always Address Communication

Training doesn't always help providers with these tough conversations. A 2013 study in JAMA randomized internal medicine residents and nurse practitioner trainees to either regular training or a special 8-session communication skills training based on simulations. Post-training, there was no improvement in quality of care or quality of end-of-life care according to patient and family ratings. In fact, the only significant difference between the patients of those trained in communication and those not trained, was that some patients showed a small but significant increase in depression symptoms.

"These findings raise questions about skills transfer from simulation training to actual patient care and the adequacy of communication skills assessment," the researchers wrote.

One problem with training programs is that they can teach a sort of empathy-by-rote, said Dieppe. Doctors might learn to say the right words, but patients don't perceive the interaction as genuine.

"We believe that a formulaic approach to communication skills is not appropriate, because this is essentially about being human, rather than being a computer," Dieppe said. More effective is probably experiential learning, he said. It's also important to let your guard down.

"Emotion is at the center of this thing, and being comfortable with your emotions is hugely important," he said.

One concrete step rheumatologists can take is including nurses and nurse practitioners in their practices, Zink said. The vast majority of doctors in Michigan rely on medical assistants, she said. Medical assistants may be cheaper, Zink said, but nurses can do more: take histories, triage patients over the phone, take large chunks of time to walk patients through their medication instructions. Patients are often more willing to open up to nurses about difficulty affording their medications or other problems.

"The nurse is more of a peer to you than this doctor who is still viewed as this superior kind of person who you don't want to burden," Zink said.

Give Patients a Sense of Mastery over their Condition

(Continued on next page.)

Give Patients a Sense of Mastery over their Condition

Another key tip is to reinforce lessons while also giving patients a sense of mastery over their condition. One way to do this, Zink said, is to preface instructions with phrases like, "As I'm sure you know" or "I know you know."

It's also important to solicit patient questions. There are educational campaigns out there trying to encourage this two-way communication. For example, "Ask Me 3" campaign by the National Patient Safety Foundation encourages patients to always ask healthcare professionals what their main problem is, what they need to do and why the instructions are important.

But perhaps the most important theme that emerges from both research and experience is listening. In chronic disease, the stresses of daily life can affect a patient's symptoms, Zink said.

"I ask every single one of my patients what's going on at home all the time," she said. "I know all their business."

If providers know that a patient's husband has cancer or that her kids have the flu, they might blame medication nonresponse on a stress-induced flare, Zink said. Or, they might miss that a patient can't afford her meds anymore because her husband's prescriptions are too expensive.

"You've got to know the whole story," Zink said. "It's really knowing the patients, knowing their home situations and devising a treatment plan that fits the patients' lives and is within the realm of an appropriate rheumatology treatment."

References:

Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the Patient's Agenda. Jama. 1999;281(3):283. doi:10.1001/jama.281.3.283.

Gong Z, Haig SL, Pope JE, et al. Health Literacy Rates in a Population of Patients with Rheumatoid Arthritis in Southwestern Ontario. The Journal of Rheumatology. 2015;42(9):1610-1615. doi:10.3899/jrheum.141509.

Horwitz LI, Moriarty JP, Chen C, et al. Quality of Discharge Practices and Patient Understanding at an Academic Medical Center. JAMA Internal Medicine JAMA Intern Med. 2013. doi:10.1001/jamainternmed.2013.9318.

Greville-Harris M, Dieppe P. Bad Is More Powerful than Good: The Nocebo Response in Medical Consultations. The American Journal of Medicine. 2015;128(2):126-129. doi:10.1016/j.amjmed.2014.08.031.

Toll E. The Cost of Technology. Jama. 2012;307(23). doi:10.1001/jama.2012.4946.

Dures E, Hewlett S, Ambler N, Jenkins R, Clarke J, Gooberman-Hill R. A qualitative study of patients’ perspectives on collaboration to support self-management in routine rheumatology consultations. BMC Musculoskeletal Disorders BMC Musculoskelet Disord. 2016;17(1). doi:10.1186/s12891-016-0984-0.

Mackenzie A. Effect of Communication Skills Training for Residents and Nurse Practitioners on Quality of Communication with Patients with Serious Illness: A Randomized Trial. The Journal of Emergency Medicine. 2014;46(3):447. doi:10.1016/j.jemermed.2014.01.010.

National Patient Safety Foundation: Ask Me 3. http://www.npsf.org/?page=askme3

Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the Patient's Agenda. Jama. 1999;281(3):283. doi:10.1001/jama.281.3.283.

Gong Z, Haig SL, Pope JE, et al. Health Literacy Rates in a Population of Patients with Rheumatoid Arthritis in Southwestern Ontario. The Journal of Rheumatology. 2015;42(9):1610-1615. doi:10.3899/jrheum.141509.

Horwitz LI, Moriarty JP, Chen C, et al. Quality of Discharge Practices and Patient Understanding at an Academic Medical Center. JAMA Internal Medicine JAMA Intern Med. 2013. doi:10.1001/jamainternmed.2013.9318.

Greville-Harris M, Dieppe P. Bad Is More Powerful than Good: The Nocebo Response in Medical Consultations. The American Journal of Medicine. 2015;128(2):126-129. doi:10.1016/j.amjmed.2014.08.031.

Toll E. The Cost of Technology. Jama. 2012;307(23). doi:10.1001/jama.2012.4946.

Dures E, Hewlett S, Ambler N, Jenkins R, Clarke J, Gooberman-Hill R. A qualitative study of patients’ perspectives on collaboration to support self-management in routine rheumatology consultations. BMC Musculoskeletal Disorders BMC Musculoskelet Disord. 2016;17(1). doi:10.1186/s12891-016-0984-0.

Mackenzie A. Effect of Communication Skills Training for Residents and Nurse Practitioners on Quality of Communication with Patients with Serious Illness: A Randomized Trial. The Journal of Emergency Medicine. 2014;46(3):447. doi:10.1016/j.jemermed.2014.01.010.

National Patient Safety Foundation: Ask Me 3.