Common Pitfalls in Clinician-Patient Communications

Date:
01/03/2017
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Introduction

Effective communication skills in medical practice are associated with enhanced patient satisfaction, greater adherence to medication regimens, improved selfmanagement, better health outcomes,1 reduced medical costs2 and decreased risks of malpractice claims.3 Ineffective communication skills can lead to the opposite with serious consequences.

Insufficient time and patient overload are often quoted by clinicians as major causes for not displaying effective communication skills and poor relationship development. However, having more time does not always lead to better communication skills and outcomes. Instead, patient-centred consultations where patients were more satisfied only appears to have lasted longer for the patients.4 In fact, it is when the clinician is hard-pressed for time that effective communication skills need to be applied for better outcomes and relationships.

Effective communication skills are like all other professional skills that can be learnt and taught, and with continued practice become natural professional habits. At the same time, clinicians must be aware of the common pitfalls in medical communications that can lead to poor outcomes and relationships.

Common pitfalls

Failure to invest in the beginning — not making the connection First impressions make lasting impressions. Failure to spend time in the beginning to establish good rapport would set the wrong tone for the rest of the interview. A good practice is to take deliberate time and effort to introduce oneself and one’s role in the patient’s care, followed by getting to appreciate the patient’s personal details. Being properly groomed, establishing eye contact and maintaining a calm tone of voice helps in making the connection. Calling the patient by his or her name during the consultation makes it personal and the patient feels respected.

When patients feel a poor connection with their physicians, they often have insufficient trust.

Failure to lay out early a collaborative agenda for the encounter

The clinician should be clear of the preferred outcome and manage the clinical encounter. It is useful in the beginning to mention the purpose of the encounter and the amount of time available, and explore the patient’s main concerns.

Failure to establish a collaborative agenda early would result in patients raising new concerns during the closing phase of the encounter.

Failure to exercise active listening

One of the commonest failures in medical encounters is to interrupt patients before they are able to complete their opening statements. This results in not being able to elicit the patient’s full story and concerns. Interruptions also make patients feel disrespected and disconnected.

Another common pitfall is inattentive listening and distraction by the case notes, computer or a handheld device such as a handphone. When the clinician is distracted and fails to comprehend what is being said, misunderstandings that require prolonged consultation may arise. The physician who is not actively listening may waste time focusing on issues that are not important to the patient and miss cues about important thoughts and feelings.5

Active listening requires a conscious effort by the listener to be silent and to maintain eye contact in order to understand what the speaker is trying to communicate, both in terms of facts and emotions. Active listening means neither interruption by the listener nor distraction by other thoughts.

Failure to explore the patient’s perspective and acknowledge emotional cues

When patients raise concerns and emotional issues, the clinician often fails to hear and returns to somatic questions. Clinicians often subconsciously block out difficult emotional and psychosocial issues as they are afraid of opening a “can of worms” and being unskilled to deal with it. This destroys the opportunity to understand and acknowledge the patient’s core concerns, ideas, feelings and expectations. Missing cues may hinder discovering the patient’s hidden agenda.

Avoid premature reassurance. Clinicians, on hearing patient’s concerns and worries, tend to be quick to offer reassurance without exploring and understanding the patient’s concerns and expectations. Ignoring the patient’s perspectives may lead the clinician to create a plan with little chance of adherence.

Empathic acknowledgement of emotional and social cues will encourage the patient to reveal hidden agendas about illness and treatment preferences that can facilitate creating an effective plan. Acknowledging patient cues may shorten consultation time because there is a decreased need for patients to restate their concerns.6

Lecturing and use of medical jargon

Lecturing occurs when the doctor is focused on completing the job and provides large chunks of information without getting feedback from the patient as to his or her understanding. The clinician would lose the patient’s attention.

Use short sentences and offer information in small bundles. Allow for pauses and silence for the patient to absorb the information, and before proceeding, ask the patient whether he or she has heard and understood. It would be best if patients can express their understanding in their own words.

The use of medical jargon results in the patient feeling disrespected and often requires additional detailed discussion. As a general rule, do not give more than three new major facts or ideas in one sitting.

Failure to clarify and explore a question before answering

There is a common habit for doctors to answer a patient’s question as though they were at the viva final examination. “Ask before you Tell” and “Explore before you Explain” are useful strategies when answering a patient’s questions or clearing doubts raised by the patient. It is important to understand the patient’s perspective and reasons for raising the issue. Understanding the patient’s perspective helps the clinician formulate a more relevant answer.

Conclusion

This article aims to induce in readers the need for a review and reflection on communication skills by highlighting some of the common pitfalls. Communicating with sick persons requires special skills as it can be hampered by physical illness, emotions of grief and anxiety with fear of the uncertainties. Ineffective communication skills can impede the quality of care and be a waste of the physician’s effort and time.

Communication skills training and practice can improve patient satisfaction, physician empathy and self-efficacy, and also reduce physician burnout.7 Communication skills should thus be recognised as an essential core professional skill and not be delegated as an optional soft or public relations skill.


References

  1. Stewart M, Brown JB, Donner A, et al. The impact of patient-centred care on outcomes. J Fam Pract 2000; 49(9):796-804.
  2. Epstein RM, Franks P, Shields CG, et al. Patient-centered communication and diagnostic testing. Ann Fam Med 2005; 3(5):415-21.
  3. Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997; 277(7):553-9.
  4. Cape J. Consultation length, patient-estimated consultation length, and satisfaction with the consultation. Br J Gen Pract 2002; 52(485):1004-6.
  5. Mauksh LB, Dugdale DC, Dodson S, Epstein R. Relationship, communication, and efficiency in the medical encounter: creating a clinical model from a literature review. Arch Intern Med 2008; 168(13):1387-95.
  6. Levinson W, Gorawara-Bhat R, Lamb J. A study of patient clues and physician responses in primary care and surgical settings. JAMA 2000; 284(8): 1021-7.
  7. Boissy A, Windover AK, Bokar D, et al. Communication skills training for physicians improves patient satisfaction. J Gen Intern Med 2016; 31(7):755-61