Effective Patient - Physician Communication

In medicine, the ability to compassionately communicate information in a fashion that can be understood and considered by the patient is key to an effective patient–physician relationship. The Accreditation Council for Graduate Medical Education identified interpersonal and communication skills as one of six areas in which physicians need to demonstrate competence (1). In this Committee Opinion, interviewing techniques and communication skills are emphasized that will help the obstetrician–gynecologist to effectively elicit patient problems and communicate reasonable treatment plans in a busy office practice.

The benefits of skilled, successful communication in medicine are many. A physician who encourages open communication often will obtain more complete information, which enables a more accurate diagnosis and appropriate counseling. This, in turn, leads to improved patient adherence and enhancement of long-term health. This model of patient–physician communication, often termed the “partnership model,” increases patient involvement in care through negotiation and consensus building between the patient and physician (2, 3). In the partnership model of communication, physicians use a participatory style of conversation (3), where the amount of time spent talking by physicians compared with patients is fairly equal. The partnership model is one of several communication models shown to improve patient care and reduce the likelihood of litigation. Other models cited in educational materials of the American College of Obstetricians and Gynecologists include the GATHER (4) and RESPECT (5) models. The GATHER model, which is composed of six elements of counseling (1] greet, 2] ask, 3] tell, 4] help, 5] explain, and 6] return), is used to help physicians maximize communication as well as confidentiality. Advocated widely for use in communicating with adolescents and in family planning discussions, the GATHER model encourages physicians to greet patients in a friendly and respectful manner and to provide a summary of what will occur during the visit. It also encourages physicians to actively listen and help patients discuss their concerns without judgment, tell patients about all of their choices for treatment, explain the next steps in treatment, and arrange a return visit for follow-up. The RESPECT model includes seven core principles (1] rapport, 2] empathy, 3] support, 4] partnership, 5] explanations,6] cultural competence, and 7] trust) to allow patients to speak freely and physicians to tailor treatment plans to an individual's norms and beliefs. The RESPECT model has been widely used to promote physician awareness of their own cultural biases and to develop the rapport necessary to assist patients from different cultural backgrounds.

Culture and Gender in Patient Communication

Regardless of any discordance that may exist between a patient's and practitioner's backgrounds, cultural beliefs, or sexual orientation, increased sensitivity by a health care provider to the patient's behaviors, feelings, and attitudes can increase patient and health care provider satisfaction. Two seminal studies have documented differences in how race and gender can affect care. Cooper and colleagues (6) found that African American patients were substantially less likely to report having equal speaking time (ie, participatory decision making) compared with white patients. Schulman and colleagues (7) reported gender and racial differences in how physicians communicated about cardiac catheterization. The Institute of Medicine issued a report detailing the importance of patient-centered care and cross-cultural communication as a means of improving health care quality across patient groups (8).

Developing Effective Communication

Developing effective patient–physician communication requires that physicians are skilled in the conduct of patient-centered interviewing, able to converse in a caring, communicative fashion, and have the capability to engage in shared decision making with their patients (9). Physicians may wish to consider five steps for effective patient-centered interviewing. A brief description of each step and the actions to be taken to effectively accomplish patient-centered interviewing are presented in Table 1 (10).The following four qualities are important components of caring communication skills: 1) comfort, 2) acceptance, 3) responsiveness, and 4) empathy (11). Comfort and acceptance refer to the physician's ability to deal with difficult topics without displaying uneasiness and accepting the attitudes a patient brings to the interview without showing irritation or intolerance. Responsiveness and empathy refer to the quality of reacting to indirect messages expressed by a patient. Using this system, the physician can gain an understanding of the patient's point of view and incorporate it into treatment (12). The following scenarios and responses represent clinical situations where these qualities can be applied.

• Scenario 1: An adolescent girl, accompanied by hermother, comes to you to discuss birth control options. During the discussion, the mother continues to express disagreement with her daughter's decision to become sexually active and proceeds to the door in order to leave the examination room.

  Effective response: You ask the mother to remain in the room briefly so that you can explain to her and her daughter what will take place during this visit. After obtaining a general history from both mother and daughter, the physician requests that the mother allow private time for discussion with her daughter. Later, a member of the office staff escorts the mother back to the examination room. The physician encourages open communication between the mother and daughter and answers any further questions.

• Scenario 2: A physician enters the examination room and greets a long-term patient, noticing that she appears tearful. On further questioning, she states, "I'm just having a bad day." The physician completes the routine history and examination without further discussion of her affect.

  Effective response: The physician shakes the patient's hand, stating, "I'm sorry you're having a hard time.

  Perhaps it will help to talk about it." The physician is then able to detect signs of depression and to offer or refer her for treatment.

Shared decision making has been defined as a process where both patients and physicians share information, express treatment preferences, and agree on a treatment plan (13). The process is applicable when there are two or more reasonable medical options (14). The physician shares with the patient all relevant risk and benefit information on all reasonable treatment alternatives and the patient shares with the physician all relevant personal information that might make one treatment or side effect more or less tolerable than others (15). This relatively new paradigm of communication is a marked departure from the traditional doctor-centered model. A recent example of a national recommendation that emphasizes shared decision making, which also garnered much public attention, is the National Institutes of Health Consensus Panel on vaginal birth after cesarean delivery (16). The Consensus Panel recommended that the decision for vaginal birth after cesarean delivery or repeat cesarean delivery should occur only after a conversation between the patient and her physician, incorporating the risks and benefits and the patient's preferences. Shared decision making can increase both patient engagement and reduce risk with resultant improved outcomes, satisfaction, and treatment adherence (17).

Recommendations for the Obstetrician–Gynecologist

The competing demands of clinical productivity (18), mounting paperwork, and the delivery of care to multiple patients, often with complex diagnoses (19, 20), can inhibit effective communication. Developing effective patient–physician communication skills requires a substantial commitment in an increasingly challenging environment with lower clinical reimbursements and higher expenses. In the long run, effective communication skills will save time by increasing patient adherence, thereby reducing the need for follow-up calls and visits. The obstetrician–gynecologist can take the following steps to improve communication:

• Use patient-centered interviewing and caring communication skills in daily practice.
• Encourage patients to write down their questions in preparation for appointments. An organized list of questions can help to facilitate an effective conversation on topics important to the patient.
• If possible, hire a communications consultant to conduct a workshop on cultural and gender sensitivity for you and your office staff.
• Hire physician extenders with patient-centered interviewing skills to assist with established patients.
• E-mail has been slowly integrated into some medical practices. If possible, consider the use of e-mail as an alternative method for established patients to communicate with their physicians or nurses for follow-up questions (21, 22). E-mail should be used in accordance with the American Medical Association Guidelines for Physician–Patient Electronic Communications (http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/young-physicians-section/advocacy-resources/guidelines-physician-patient-electronic-communications.shtml).
• Advocate for sustainable practice models that allow for visits of sufficient duration to provide an opportunity to address multiple patient concerns

ACOG Resources

Cultural sensitivity and awareness in the delivery of health care. Committee Opinion No. 493. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:1258–61.

Health literacy. Committee Opinion No. 491. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:1250–3.

Partnering with patients to improve safety. Committee Opinion No. 490. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:1247–9.

Other Resources

The resources listed are for information purposes only. Referral to these resources and web sites does not imply the endorsement of the American College of Obstetricians and Gynecologists. This list is not meant to be comprehensive. The exclusion of a source or web site does not reflect the quality of that source or web site. Please note that web sites and URLs are subject to change without notice.

Institute for Healthcare Communication
http://www.healthcarecomm.org.

Massachusetts General Hospital, Disparities Solutions Center
http://www2.massgeneral.org/disparitiessolutions

Walker JD. Enhancing physical comfort. In: Gerteis M, Edgman-Levitan S, Daley J and Delblanco TL, editors. Through the patient's eyes: understanding and promoting patient-centered care. San Francisco (CA): Jossey-Bass; 1993. p. 119–53.

References

1. Accreditation Council for Graduate Medical Education. Common program requirements: general competencies. Chicago (IL): ACGME; 2007. Available at: http://www.acgme.org/outcome/comp/GeneralCompetenciesStandards21307.pdf. Retrieved January 18, 2011.
2. Roter DL. Physician/patient communication: transmission of information and patient effects. Md State Med J 1983;32:260–5.
3. Roter DL. Patient question asking in physician-patient interaction. Health Psychol 1984;3:395–409.
4. American College of Obstetricians and Gynecologists. Talking with teens. In: Tool kit for teen care. 2nd ed. Washington, DC: ACOG; 2009.
5. American College of Obstetricians and Gynecologists. Guidelines for women's health care: a resource manual. 3rd ed. Washington, DC: ACOG; 2007.
6. Cooper-Patrick L, Gallo JJ, Gonzales JJ, Vu HT, Powe NR,Nelson C, et al. Race, gender, and partnership in the patient-physician relationship. JAMA 1999;282:583–9.
7. Schulman KA, Berlin JA, Harless W, Kerner JF, Sistrunk S,Gersh BJ, et al. The effect of race and sex on physicians' recommendations for cardiac catheterization [published erratum appears in N Engl J Med 1999;340:1130]. N Engl J Med 1999;340:618–26.
8. Institute of Medicine (US). Unequal treatment: confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press; 2003.
9. Simpson M, Buckman R, Stewart M, Maguire P, Lipkin M,Novack D, et al. Doctor-patient communication: the Toronto consensus statement. BMJ 1991;303:1385–7.
10. Smith RC. Patient-centered interviewing: an evidence based method. 2nd ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2002.
11. Myerscough PR, Ford MJ. Talking with patients: keys to good communication. 3rd ed. New York (NY): Oxford University Press; 1996.
12. Suchman AL, Markakis K, Beckman HB, Frankel R. A model of empathic communication in the medical interview. JAMA 1997;277:678–82.
13. Peek ME, Wilson SC, Gorawara-Bhat R, Odoms-Young A, Quinn MT, Chin MH. Barriers and facilitators to shared decision-making among African-Americans with diabetes. J Gen Intern Med 2009;24:1135–9.
14. Whitney SN, McGuire AL, McCullough LB. A typology of shared decision making, informed consent, and simple consent. Ann Intern Med 2004;140:5–9.
15. Kaplan RM. Shared medical decision making. A new tool for preventive medicine. Am J Prev Med 2004;26:81–3.
16. National Institutes of Health Consensus Development conference statement: vaginal birth after cesarean: new insights March 8-10, 2010. National Institutes of Health Consensus Development Conference Panel. Obstet Gynecol 2010;115:1279–95.
17. de Haes H. Dilemmas in patient centeredness and shared decision making: a case for vulnerability. Patient Educ Couns 2006;62:291–8.
18. Mechanic D, McAlpine DD, Rosenthal M. Are patients' office visits with physicians getting shorter? N Engl J Med 2001;344:198–204.
19. Nutting PA, Rost K, Smith J, Werner JJ, Elliot C. Competing demands from physical problems: effect on initiating and completing depression care over 6 months. Arch Fam Med 2000;9:1059–64.
20. Haas LJ, Leiser JP, Magill MK, Sanyer ON. Management of the difficult patient. Am Fam Physician 2005;72:2063–8.
21. Ye J, Rust G, Fry-Johnson Y, Strothers H. E-mail in patient-provider communication: a systematic review. Patient Educ Couns 2010;80:266–73.
22. Neill RA, Mainous AG 3rd, Clark JR, Hagen MD. The utility of electronic mail as a medium for patient-physician communication. Arch Fam Med 1994;3:268–71.