This week I came across two articles in the press concerning doctor-patient relationships and communication. I began to reflect on what makes communication between doctor and patient most successful and many questions surfaced. In the New York Times, a new study published in Annals of Internal Medicine was referenced. In this study, the way in which doctors communicate non-verbally was examined. Non-verbal communication was often discordant to the message being relayed, particularly when African American physicians were delivering bad news to white patients. Previous studies showed similar differences in communication and found that female physicians were delivering discordant verbal and non-verbal messages to male patients. Certainly cultural and gender differences must play a large role in how we do our jobs–but what can we do to improve? In a second article published in the Wall Street Journal, referenced a survey of 1891 physicians from the Journal of Health Affairs. The investigators found that a significant number of respondents were not honest with patients. Nearly half admitted that they had described a patient’s prognosis as more positive than it really was and 20% stated that they had kept medical errors hidden from patients. Interestingly, the study found that cardiologists and surgeons were more likely to achieve open and honest communication. Patients need clear messages and accurate information in order to make good healthcare decisions. When delivering bad news, it is important to provide some glimmer of hope–how much is enough?
How Can this be?
In Medical Schools today, communication is emphasized. When I was in training in 1996 at Bowan Gray School of Medicine at Wake Forest University, we had regularly observed (through a two way mirror) and graded doctor-patient interactions during the first year. Not only were the history and physical exam skills evaluated, but the “patient” (typically an actor from the NC School of the Arts) would provide a grade for compassion, communication, etc. Today’s medical schools continue to emphasize communication. Entire classes and lecture packages have been developed in an effort to arm our emerging physicians with superior communication skills. But, given the recently published studies, maybe we are not focusing on the total communication package. Few lessons in non-verbal communication skills have been delivered. Discordant verbal and non-verbal messages serve only to confuse and frighten patients. Moreover, more discussions on medical ethics, end of life issues and honest communication are clearly warranted. The basic tenet of a doctor-patient relationship is TRUST. Without it, no cooperation in the delivery of healthcare is possible. Today, more than ever, preventative health care is a two way street–a contract between provider and patient. Trust and honest communication is paramount for success.
How can we Improve?
We must start by better educating ourselves and our physicians in training in the art of communication. According to Stuart Foxman, communication consists of three distinct components: 1. What we say, 2. How we say it (tone, pitch and volume), 3. non verbal body language. Each component is an integral part of the doctor patient relationship and any one part can destroy the communication process. Those of us in practice must self evaluate and identify communication inadequacies and areas that must be improved. Annual Scientific sessions (such as ACC in March) should begin to include workshops on communication and more sessions on medical ethics. As physicians in practice, we must set an example for the physicians in training in medical school, residency and fellowship. Although most of us are unaware, we mentor trainees as much non- verbally as we do with didactic teaching.
It is obvious to all that hiding errors from patients is unethical and discordant with the Hippocratic Oath–honesty is the basis of all communication. Multiple studies have demonstrated that patients are much less likely to litigate when a physician communicates regularly and effectively and has been truthful about any medical errors. We must treat patients and families as we would want to be treated. Doctors are not immune from mistakes but how a physician handles a mistake is what separates average caregiver from exceptional healer.
So remember, as you meet with patients and families this week, be cognizant of how and what you say–Speak the Truth and Say what you mean!