Physician to Patient Communication: Speak the Truth, Say what you mean!

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!

One response to “Physician to Patient Communication: Speak the Truth, Say what you mean!

  1. DR Campbell, I’m a cancer patient, who is glad to see here that there are still doctors (like you) who care about establishing and maintaining a good communication with their patients.

    From my experience it is becoming more rare though to find doctors who work on communicating the right way with their patients and I have been starting to wonder why.

    To try understand these symptoms of poor communication and try help turn around its serious consequences for patients, which are poorer not better health and waste of one’s time and money resources, I have begun collecting information on such ‘poor doctor-patient’ communication from myself as well as other patients as well as ‘other side’ reports by doctors and any studies related to the subject.

    I’m also trying to establish what each, patient and doctor, believe the ‘why’, the motive, should be for establishing and keeping good communication between patient and doctor. Although some patients and doctors express some common goals, more often patients’ and doctors’ goals are not shared. Without shared goals, no good communication will ever occur.

    The primary goal of improving the health of the patient in exchange for financial remuneration and personal appreciation has become very rare, so a mutual win/win focus is hard to find.

    That missing trader principle means there is an unequal relationship between doctor and patient, usually an adversarial one, which is not in either one’s interest.

    No patient needs an altruist nor should he expected to sacrifice his health, time and money to feed an illusion that a doctor is doing his healing job, offering value for value. No doctor has also use for a moocher, who does not pay for his time, who is a liability hazard, or who puts any undue unearned burden on the doctor.

    Apart from the lack of the right motivation with doctors and/or patients, I also noticed a lack of verbal and non-verbal communication skills with the bulk of doctors, not just with me but with fellow patients.

    So I was surprised to read here that doctors actually get trained in communication. That training seems largely a failure. Not so long ago researchers in the Netherlands (University of Nijmegen) even discovered that doctors who were treated as patients were unhappy about their colleagues communication skills and in general the patient-doctor communication was experienced as deficient by everyone.

    Beyond motivation, what seems to be lacking is an understanding of the psychology behind verbal and non-verbal communication in general. Like doctors, patients need psychological visibility, but are instead treated mainly like they are invisible. Instead they have a robot in front of them, whose buttons they push. The robot asks a few questions, does few tests and grades the patient as pertaining to group X or Y in his collection of memorized ‘group oriented studies based profiles’. and automatically the ‘group appropriate’ test or treatment gets initiated.

    There is rarely an acknowledging and consideration of the individual’s personal situation, his character, his psychological state of mind, his personal home and work situation, his body’s deviating clinical symptoms, the different degree of urgency for a test or treatment, different life expectancy, personal habits etc.

    Given all this, achieving mutual psychological visibility by changing one’s motivation one’s thinking habits and by using verbal and non-verbal mirroring, should be at the forefront of a physician’s drive to change his communication with his patient.

    Not only will he achieve much better outcomes resulting in more professional pride and therefore become more self-assured (many docs are notoriously insecure), but he’ll likely also be better rewarded financially for excelling. The whole job will become more fun.

    I know of some such kind of doctors, so it is feasible. I wish they would teach these skills more to their colleagues (some do).

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