by Douglas A Drossman, MD
Changes in our healthcare system have been associated with a deterioration in the patient-provider relationship (PPR). For the clinician, increased administrative tasks and certification requirements, along with pressures to see more patients, have reduced clinic visit time. Thus, the medical interview is abbreviated, the quality of the interaction is diminishing, and the patient-provider relationship suffers. Effective communication skills are a way to remedy this problem. Implementing patient-centered care as originally defined by the Institute of Medicine (IOM) almost 20 years ago1 can help.
What is Patient-Centered Care?
Patient-centered care means that care is respectful of, and responsive to, patient preferences, needs and values, and that patient values guide clinical decisions. Some of the components to establishing patient-centered care include: respect for the patient’s knowledge and perspective, providing physical comfort and emotional support, offering education and reassurance, being accessible and collaborative, and making decisions based on patient preferences. To accomplish these goals, the clinician uses effective communication strategies to understand the full nature of the patient’s symptoms and their illness experience in addition to their needs, perceptions, concerns, and impact the illness is having on their life.
Twelve pearls about patient-centered care can be used to establish an effective provider-patient relationship2:
- Listen actively. Don’t jump in with questions unless you’ve made the effort to understand the patient’s perspective. “Don’t just do something, stand there.”
- Understand the patient’s agenda. The issues patients seek to address are often not stated because they have not been given the opportunity, or have not been aware of them until the clinical visit. Common concerns relate to the impact of the illness on their life, the possibility of cancer, fear for future consequences and many more. Discussion of these issues improves patient satisfaction. Here are four important questions to ask on the first visit:
- What brought you here today?
- What do you think you have?
- What worries or concerns do you have?
- What do you feel I can do to help?
- Empathize. An empathic statement would be: “I can see how difficult it has been to manage with your pain.” Empathy incorporates four components:3
- Perspective taking: Seeing the world as the patient sees it.
- Being non-judgmental.
- Recognizing the emotions and understanding the patient’s feelings.
- Communicating that understanding to the patient.
- Validate thoughts and feelings. Validating the patient’s thoughts and feelings shows that you are acknowledging and legitimizing them. Though you may not necessarily agree, you are still accepting their perspective. A validating statement for a patient who feels stigmatized by others who say the problem is due to stress would be: “I can see you are upset when people say this is due to stress and you know it’s real.” This statement also opens the door to further dialog about the role of stress in illness.
- Set realistic goals. Some patients with chronic illness may seek a rapid diagnosis, perhaps of a structural disease, and a cure. However, the clinician may see the need to focus on ongoing management with realistic expectations for outcome. This difference in perspective needs to be reconciled. Here, you can say: “I can understand how much you want these symptoms to go away, but they are longstanding, and as such we need to reset our expectations. If we could seek to reduce your symptoms by 30 % over the next several months, would that help?”
- Educate. Education is a four-step iterative process:
- Elicit the patient’s understanding.
- Address misunderstandings.
- Provide information consistent with the patient’s understanding.
- Check the patient’s understanding of what was discussed.
- Reassure. Reassurance requires you to:
- Identify the patient’s worries and concerns,
- Acknowledge and validate them,
- Respond to these specific concerns.
- Avoid false reassurances (e.g., “don’t worry about it”) that can sound dismissive, as if their feelings aren’t valid.
- Negotiate. Patient-centered care requires mutual agreement on diagnostic and treatment options. The doctor, after eliciting the patient’s personal experience, and understanding of and interests in various treatments, then provides choices (rather than directives) that are consistent with the patient’s beliefs. IOM guidelines require the patient to make the final decision1.
- Help the patient take responsibility. Patients with chronic illness do best when they take responsibility for their care and clinicians must encourage this. So rather than asking the patient: “How is your pain doing?” you might say: “How are you managing with your pain?” The second question encourages the patient, rather than the clinician, to take an active role in management. This also offsets clinicians from feeling pressured to take more responsibility than needed. With treatment, it is wise to offer several treatment approaches with a discussion of their risks and benefits so the patient can make the choice.
- Be there. This means providing support and a listening ear. Sometimes patients disclose personally meaningful and sensitive issues that have no simple solutions. They are not seeking a simple solution as much as to know they are being heard, understood, and supported.
- Establish boundaries. For some patients, it’s important to establish and maintain “boundaries” related to frequent phone calls, unexpected visits, a tendency toward lengthy visits, or unrealistic expectations for care. The clinician needs to present expectations in a way that is not perceived as rejecting or belittling to the patient yet is also consistent with personal needs. For example, if a patient calls by phone after hours, the clinician can gently remind the patient that it would be better to have the discussion in the office or at the next visit.
- Be aware of time constraints. As discussed, clinicians have less and less time to spend with patients. Learning high-quality communication skills can save time by establishing a satisfying relationship with only a few simple techniques as noted. For example, some patients may desire more time or make frequent phone calls. Setting limits on time can be accomplished by scheduling brief but regular appointments of a fixed duration, rather than attempting to extend the time of a visit.
Learn More About Patient-Centered Care
The Rome Foundation, in collaboration with the Center for Education and Practice of Psychosocial Care, has established “What Do You Hear,” a program to teach clinicians ways to improve their communication skills. This is being offered through a variety of formats including educational videos, workshops, webinars and train-the-trainer programs. For further information about the What Do You Hear program or to obtain our educational tools, please go to: https://romedross.video/2KPTYzC or contact Johannah Ruddy at firstname.lastname@example.org.
- Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Vol 1. 1 ed: National Academy of Sciences; 2001.
- Drossman DA. 2012 David Sun Lecture: Helping your patient by helping yourself: How to improve the patient-physician relationship by optimizing
communication skills. American Journal of Gastroenterology. 2013(108):521-528.
- Wiseman T. A concept analysis of empathy. J Adv Nurs. 1996;23(6):1162-1167.