Communication is the Foundation of Patient Engagement
As a child, I, and many other baby boomers like myself, visited a doctor who worked out of his home. There were no appointments; we sat on a bench in his sun porch as we were called one by one by the only other person there, his nurse. The doctor was the one who communicated with us, diagnosed us, and treated us. Then we paid our bill, often in cash, and our appointment was over. I never felt unheard or angry, I was grateful for his knowledge and his willingness to care for me.
Today we live in a very different world, we are all part of a system. As providers we have had to learn to navigate that system and, more importantly, we have an obligation to help our patients navigate that system to receive quality care that is cost effective, provides value, and leaves patients feeling heard and cared for. Most of us do this as well as we know how, learning through our own experiences and the experiences of those who have taught us. As providers, this is very difficult because the system requires so much more than patient care: a cumbersome EMR, regulations, federal laws about what we can do and charge, a patient constituency that has become demanding and litigious, to name a few.
As providers we have had to learn to navigate that system and, more importantly, we have an obligation to help our patients navigate that system to receive quality care that is cost effective, provides value, and leaves patients feeling heard and cared for.
So what is a doctor to do, in face of these obstacles?
Communication is a skill we learn from birth by copying our family, our teachers, and our peers. Only recently have medical and advanced practice providers had the opportunity to study communication as a science and learn skills to help them engage patients in a positive way.
For the last three years, I have taught and mentored a small group in a humanities course simply called “Communication” at Penn State Health. The course meets weekly for half a year and consists of a plenary session and small group discussions. We start by looking at how each individual communicates by examining how our family communicated, how our culture can produce unrecognized bias, and how we deal individually with conflict and nonverbal communication.
We then move to a dyad format of studying standardized patients and clinical scenarios. Over several weeks, students view and self-critique these situations. We then look at more complex issues like team meetings, family meetings, and delivering bad news. We finish with a few sessions on how communication is maximized in a health care system.
This communication course is invaluable in developing a foundation for engaging patients using good communication. In lieu of a formal course, there is a huge body of literature that speaks to connecting with patients as an essential task of a clinician. In the next few paragraphs, I want to summarize the Four Habits Approach to clinical communication from Frankel and Stein published in the J Med Pract Manage in 2001. While that was some time ago, these habits continue to work today to engage patients and increase patient satisfaction.
Invest in the beginning
Setting the tone in that first minute is so important: promptness, a comfortable exam room, a well-dressed and engaging physician, appropriate introductions, and perhaps a social comment or a comment about an aspect of the patient’s history which indicates you are knowledgeable of their medical history.
To invest in a visit from the beginning, physicians should
- Adapt their speech speed to that of their patient’s
- Start with open-ended questions
- Repeat back concerns so there is certain understanding
- Discuss the reason for the visit
These techniques will allow faster establishment of the reason for the visit, increase diagnostic accuracy, decrease the potential for conflict, and facilitate negotiating an agenda. In the long run, this will result in a more efficient visit.
Elicit the patient’s perspective
In order to elicit the patient’s perspective, physicians should
- Ask the patient about their point of view on what is causing their problem
- Ask for their expectations of the visit
- Ask how the problem has affected their life
These techniques respect diversity and social differences, uncover hidden concerns, and allow the patient to provide important diagnostic clues.
To demonstrate empathy, physicians should:
- Look for opportunities to use brief empathetic statements like, “That must have been very difficult to deal with”
- Name a likely emotion: ” That sounds very upsetting”
- Use nonverbal empathy as appropriate: a pause, a touch, or facial expression
- Be aware of your own emotions and take a break if necessary
These habits help to build trust and lead to better diagnostic information, adherence, and outcomes. These qualities make physicians more human and, with the earned trust of the patient, make setting limits or saying “no” easier.
Invest in the final part of the visit
To invest in the final part of the visit, physicians should
- Frame the diagnosis in terms of the patient’s original request if possible
- Explain the rationale for tests and therapy
- Review side effects of therapies
- If there are options, involve the patient in the decision-making process
These habits increase the potential for collaboration, improve adherence, and encourage self-care.
Clinicians should strive to manage the care of patients within a system to maximize quality, value, and cost-effectiveness. A patient will have confidence in a physician if that physician has the skills to access and utilize the best aspects of the system for the patient. The Four Habits Approach to clinical communication provides a validated approach to clinician behaviors that maximizes trust, collaboration, efficiency, patient satisfaction, and patient engagement.
Patient engagement depends on many clinical attributes, foremost being the ability to communicate in a manner that engenders mutual respect, clinical curiosity, diagnostic skill, and attention to decision making preferences and cultural issues. This approach provides for a professional interaction and excellent results.