(Reaffirmed 2013, Replaces No. 320, November 2005)
ABSTRACT: Actively involving patients in the planning of health services is recommended as a means of improving the quality of care. This can increase patient engagement and reduce risk resulting in improved outcomes, satisfaction, and treatment adherence.
The foundation for a positive physician–patient interaction is formed by establishing a partnership and creating a meaningful dialogue. Accomplishing this in a brief office visit may be challenging, but with adequate planning these encounters can be structured in a positive way. Improving communication with patients, listening to their concerns, and facilitating active partnerships should be central to any patient safety strategy (1). Involving patients in the planning of health services also is recommended as a means of improving the quality of care (2). Additionally, several studies indicate that physician–patient communication problems may account for an increase in medical professional liability actions (3, 4).
Patients are responsible for providing their physicians with the information that is necessary to reach an accurate diagnosis or treatment plan. To facilitate this process, patients should be encouraged to discuss the reasons for their visits and use the "Ask Me 3" questions developed by the Partnership for Clear Health Communication at the National Patient Safety Foundation and adopted by the World Health Organization as follows (5):
- What is my primary problem?
- What do I need to do?
- Why is it important for me to do this?
In response, physicians should actively listen to engage their patients. Physicians also can solicit the patient's concerns and opinions by asking open-ended questions and asking patients to share key information such as their medical histories (including illnesses, immunizations, and hospitalization), medication history (including over-the-counter [OTC] medications and dietary supplements), and any allergies, reactions, or sensitivities experienced after taking medications. In addition to the physician, other staff, such as nurses and physician assistants, may play an important role in ensuring appropriate communication.
According to an Institute of Medicine report, “nearly half of all American adults—90 million people—have difficulty understanding and acting upon health information” (6). The Institute of Medicine defines health literacy as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions" (6). Cultural barriers also can impede physician–patient communication. Consequently, it is important for clinicians to use proven strategies to facilitate communication with patients. Listed as follows are examples of useful methods (7):
- Speaking slowly and using plain, nonmedical language
- Limiting the amount of information provided and repeating the information
- Using teach-back or show-me techniques (asking the patient to repeat any instructions given) to confirm that the patient understands what has been explained
- Encouraging patients to ask questions
- Providing written materials to reinforce oral explanations
The tool kit entitled Health Literacy and Patient Safety: Help Patients Understand, 2nd edition, developed by the American Medical Association, includes an instructional video and a detailed manual for clinicians that may be helpful (7).
Informed consent is a process, not a form (8). At the end of this process, the patient should understand her diagnosis, recommended treatment, potential complications, and treatment options. This discussion should be documented in the medical record. It often is helpful to invite the patient to bring a relative or a close friend to this discussion because this may help the patient retain the information given to her. There are many commercially available videotapes and printed materials, including those produced by the American College of Obstetricians and Gynecologists that can reinforce—but not replace—this process.
In addition to informed consent is the model of shared medical decision making. First described in the 1970s, shared medical decision making can be considered in certain cases requiring informed consent (9). Simple informed consent is appropriate in situations of significant risk, particularly when only one treatment option exists. Shared medical decision making, however, applies when there are two or more reasonable medical options (10). Shared medical decision making is a process in which the physician shares with the patient all relevant risk and benefit information on all 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 (11). It can increase patient engagement and reduce risk resulting in improved outcomes, satisfaction, and treatment adherence (12). In a study of breast cancer patients, a majority (97%) preferred a shared decision-making model with a collaborative approach to proceed with a treatment choice (13), rather than simple informed consent.
In reality, decision making is a continuum with the physician leading the discussion on one end, and with patients making the decision on the other end. Although medical knowledge is tipped toward the provider end of the continuum, in shared medical decision making, a middle ground is sought that incorporates sound medical care and a patient's personal preferences.Patient-centered goals also may have a part in the decision-making process. However, physicians should provide their clinical judgment on best choices when they believe a clear benefit exists.
Medication errors are the largest source of preventable adverse events. It is important for patients to provide their physicians with a list of the prescription and nonprescription medications they take, including vitamins and herbal supplements. Whenever new prescriptions are given, patients should be told why the medication is being prescribed and given instructions for taking the medication. For example, if a medication is to be taken three times per day, the patient should be told what time of day the medication should be taken, whether it should be taken with food or without food, how much should be taken at one time, how long the medication should be continued, possible interactions with other medications the patient is taking, and whether any medications (including OTC medications), foods, or alcohol are contraindicated while taking this medication. Physicians should encourage their patients to maintain a list of all the medications, vitamins, herbal supplements, and OTC medications they are taking and share the list with any other physicians they may be seeing. Medication forms or pill cards may be useful to facilitate this process (see Resources).
Physicians should discuss how test results will be communicated. Tracking strategies should be developed for the office and may include logbooks or computer prompts. The goal should be communication of every test result to the patient on a timely basis. Tracking of high-priority tests (eg, Pap tests, mammograms, and biopsy results) should be established. Clinicians should inform their patients that not receiving results does not necessarily mean that there is not an issue. Patients should be given a reasonable time frame within which they should expect to be informed about their test results, and they should be encouraged to call if they have not heard from the office at the end of that period.
Partnering with patients to improve communication results in increased patient satisfaction, increased diagnostic accuracy, enhanced adherence to therapeutic recommendations, and improved quality of care.
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.
Effective patient–physician communication. Committee Opinion No. 492. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:1254–7.
Health literacy. Committee Opinion No. 491. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:1250–3.
Jacobson KL, Kripalani S, Gazmararian JA, McMorris KJ.How to create a pill card (Prepared under contract No. 290-00-0011 T07). AHRQ Publication No. 08-M016. Rockville (MD): Agency for Healthcare Research and Quality; 2008. Available at: http://www.ahrq.gov/qual/pillcard/pillcard.pdf. Retrieved July 6, 2010.
Surgery and patient choice. ACOG Committee Opinion No. 395. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008;111:243–7.
- Vincent CA, Coulter A. Patient safety: what about the patient? Qual Saf Health Care 2002;11:76–80.
- Crawford MJ, Rutter D, Manley C, Weaver T, Bhui K, Fulop N, et al. Systematic review of involving patients in the planning and development of health care. BMJ 2002; 325:1263.
- Hickson GB, Clayton EW, Githens PB, Sloan FA. Factors that prompted families to file medical malpractice claims following perinatal injuries. JAMA 1992;267:1359–63.
- Hickson GB, Clayton EW, Entman SS, Miller CS, Githens PB,Whetten-Goldstein K, et al. Obstetricians' prior malpractice experience and patients' satisfaction with care. JAMA 1994;272:1583–7.
- National Patient Safety Foundation, Partnership for Clear Health Communication. Ask me 3. Available at: http://www.npsf.org/askme3. Retrieved July 6, 2010.
- Institute of Medicine (US). Health literacy. A prescription to end confusion. Washington, DC: National Academies Press; 2004.
- Weiss BD. Health literacy and patient safety: help patients understand. 2nd ed. Chicago (IL): American Medical Association Foundation; 2007. Available at: http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf. Retrieved July 6, 2010.
- Informed consent. ACOG Committee Opinion No. 439. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:401–8.
- Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med 1997;44:681–92.
- Whitney SN, McGuire AL, McCullough LB. A typology of shared decision making, informed consent, and simple consent. Ann Intern Med 2004;140(1):54–59.
- Kaplan RM. Shared medical decisionmaking. A new tool for preventive medicine. Am J Prev Med 2004;26(1):81–83.
- de Haes H. Dilemmas in patient centeredness and shared decision making: a case for vulnerability. Patient Educ Couns2006;62:291–8.
- King JS, Moulton BW. Rethinking informed consent: the case for shared medical decision-making. Am J Law Med 2006;32:429–501.