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The Importance of Clinician-Patient Communication Behaviors

Clinician-patient communication is the primary process by which medical decision-making occurs, and the communicative features of the consultation (e.g., information exchange, shared decision-making) can influence outcomes. Poor communication is associated with worse patient satisfaction, less trust, more complaints and malpractice claims, and worse health outcomes.

Specific communication behaviors of cliniciansand patients can be targeted to improve communication. These include patients' active communicative behaviors such as asking questions, being assertive, and communicating concerns. They also include clinicians' patient-centered behaviors such as being supportive, giving information, and building a relationship.

Role of Empathy

Empathy is a powerful method to provide support, yet it is infrequently used by clinicians. When clinicians' focus is largely biomedical, cognitive tasks of determining diagnoses and treatment recommendations occupy their attention. As a result, clinicians find that it is challenging to respond to patients' emotional needs.

The VA HSRD Center for Management of Complex Chronic Care evaluated clinicians' empathic responses given to Veterans undergoing work-up or treatment decision-making for lung cancer. As part of this work, we characterized the types of "clues" or "empathic opportunities" that patients might raise in a medical encounter.¹ We classified the empathic opportunities in patients' statements as relating to the bad news/impact of lung cancer, difficulty with diagnosis or treatment, and health system barriers, among others. Our hope is that such a typology will be useful for clinicians in raising awareness of patients' emotional needs and as an educational framework to help clinicians learn to respond empathically.

We also noted that empathy was infrequent and given late in the medical encounter, representing an all too common pattern where clinicians provided too little empathy and provided it too late in the encounter. Earlier provision of empathy and provision of these empathic responses periodically throughout the encounter ("interval empathy") are likely to allow clinicians to build understanding and validate patients' concerns, and progressively build trust and rapport with patients.

Fortunately, clinicians can be taught to express empathy, a behavior that can be brief and does not prolong encounters. Our classification of empathic opportunities may be useful in educational modules for teaching clinicians to express empathy.

Why should we consider interventions to improve patients' communication? It would seem much more efficient to just focus efforts to improve communication on clinicians (because there are fewer physicians and each physician has numerous patients). One challenge is that clinicians have developed routines of communication that can be difficult to change. Though interventions to change clinician behavior often are lengthy, interventions to improve patients' communication do not need to be as intensive and can often be administered in the waiting room immediately prior to the visit.

In preparation for the development of an intervention for Veterans, we conducted several focus group interviews to evaluate patients' perspectives on using active communicative behaviors with their physicians. Veterans perceived that they had little influence on the course of their own medical encounter. Veterans felt that clinicians' styles that were paternalistic, pushy, lecturing, and jargon filled discouraged their participation in the encounter. Also, patients admitted that they withheld information and avoided asking questions because of guilt, embarrassment, or fear of the clinician devaluing the importance of their questions or concerns.² These results are useful for educational efforts to increase awareness of the problems that patients perceive when communicating with physicians.

Looking Forward

Efforts to improve clinician-patient communication should recognize that communication is a two-way street. Patients who ask questions are more likely to influence their clinician to provide answers, and clinicians who are supportive are more likely to encourage patients to be active participants in the interaction (e.g., ask questions). These two-way dynamics between patient and clinician mean that improvement in communication of patient, clinician, or both, can improve overall communication.

It is important to make efforts to improve communication in medical encounters because patients who have difficulty communicating with their clinician are less involved in the visit, receive less information from their clinician, and are less satisfied with care. Effective communication by both patients and clinicians can produce better patient self-management, adherence to treatment recommendations, and patient follow-up, thereby lessening the impact of disease on functional status.

Interventions to improve communication are often not even attempted in clinical practice. Efforts to refine and develop interventions that can be implemented are an important goal of future research.

References

1. Morse DS, Edwardsen EA, Gordon HS. Missed Opportunities for Interval Empathy in Lung Cancer Communication. Archives of Internal Medicine 2008; 168(17):1853-58.
2. Gordon HS, Sharp LK. Diabetes Patients' Perceptions of Barriers to Communicating with Physicians. Journal of General Internal Medicine 2010. Abstract.