Physician-Patient Communication
It is within the context of communication that the therapeutic alliance between physician and patient is formed. When communication with a patient is nonjudgmental, respectful, and genuine, the stage is set for a successful therapeutic alliance. Medical knowledge is vitally necessary, but alone it is insufficient to accomplish the tasks of caring for a patient. It is the ability of the physician to translate medical knowledge for the patient and to enlist the trust of the patient that will ultimately lead to good health care for the patient.
Good communication has several beneficial effects on the relationship between the physician and the patient. It improves patient satisfaction, adherence,1 and health. It also improves physicians’ satisfaction with their work and the accuracy of information they obtain from patients and decreases the likelihood that physicians will be sued for malpractice.
1 The term adherence is used throughout this chapter in preference to compliance.
The impact of good communication on patient satisfaction is the best studied of these benefits. Ware and colleagues extensively reviewed the evidence for the validity of using patient satisfaction and other patient rating scales, concluding that patients’ ratings of interpersonal aspects of care provide not only useful and valid information for quality assessment but also the best source of data on the interpersonal aspects of care.
Patients generally want more information than their physicians give them. The amount of information given to the patient strongly correlates with patient satisfaction. Physicians spend a small fraction of their time giving information, 1 minute out of 20, and believe that they spend more time than they actually do. Thus the correlation between the amount of information patients receive and their satisfaction with the visit is a strong and consistent observation in the medical literature.
Many other physician behaviors also correlate with satisfaction. These include courtesy, attention, listening, empathy, and sympathy. Patients whose physicians communicate and interpret emotions well and are friendly, concerned, take time to answer questions, and give explanations are more satisfied. Patients rate their physicians positively if they are encouraging, open, and attentive and negatively if they dominate the encounter.
Physicians’ personal qualities are rated highly if the encounter centers on the patient rather than on the physician’s concerns. Physicians who ask many directive questions and keep tight control over the interaction tend to have patients who feel that their physicians do not listen to them.
Physician satisfaction, although not as well studied as patient satisfaction, is very important for physicians’ personal and professional lives. Physicians find reward and meaning in their interpersonal relationships with patients. The quality of those relationships is directly related to physician satisfaction with their work. Good communication with patients will improve the quality of the relationship and thus improve physician satisfaction.
In 1988, George Engel said, “The interview is the most powerful, encompassing, sensitive, and versatile instrument available to the physician.” In a 1984 study, Beckman and Frankel discovered that physicians frequently interrupted patients before they completely expressed their concerns, and rarely returned to patients’ initial concerns. They found that physicians controlled the interview with directive questions and they postulated that these interviewing tactics resulted in a loss of relevant information. They also found that these behaviors resulted in an incomplete clinical picture and disorganized care, thus leading to the collection of inaccurate information. Accurate information is lost when physicians use medical jargon. In one study, 50% of physician-patient interactions were adversely affected by the physicians’ use of medical jargon. Patients frequently believed they understood the jargon, but actually did not.
Other behaviors by the physician interfere with accurate data collection. Excessive control of the interview by the physician limits patients’ ability to communicate all of their concerns; hence the patient database is flawed. The way a question is asked has an important impact on the information received. Patients who are asked “What concerns you about this problem?” give better information than patients who are asked “What worries you about this problem?” The use of closed-ended questions (questions that have yes/no answers) limits the ability of patients to describe symptoms in their own words. In summary, physicians can improve the accuracy of their medical interviews if they use open-ended questions, allow patients to fully answer a question before interrupting, and avoid the use of medical jargon.
The relationship between improved health and good communication is more difficult to study than the correlation between patient satisfaction and good communication. Outcomes are influenced by many more variables and are temporally more distant. However, evidence indicates that good communication between physicians and patients correlates with good health outcomes. Patients with peptic ulcer disease who are involved in their own care through shared decision making with their physicians have less functional impairment due to their illness. When there is agreement between physicians and patients about the nature and severity of the patient’s health problem, improvement in or resolution of the problem occurs more often. Physicians who are less controlling, give more information, and show more emotion have patients with fewer functional limitations, lower blood pressure, and lower blood glucose levels. Patients who can express their emotions, both positive and negative, have improved health outcomes; in addition, when the ratio of patient to physician talk is high, patients are healthier. Open-ended questions are superior to directive questions. Patients who are allowed to tell their story in their own words have lower blood pressures. In a study in which anesthesiologists were trained to give patients more detailed information about what to expect during their hospitalization, the patients required less pain medicine and left the hospital earlier.
Physicians who communicate well are less likely to be named in a lawsuit. Patients of frequently sued physicians are more likely to say they were rushed, never received explanations, felt ignored, and felt their physicians did not communicate with them. There was no correlation between quality of care and adverse outcomes and malpractice claims in one study. These studies and others suggest that physicians are sued because patients are unhappy with their care and not because of poor quality of care.
