Effective Patient-Physician Communication - A Concise Review

Abstract

Current medical care is heavily reliant on the use of evidence-based guidelines dealing with diagnosis and therapy. The burgeoning medical literature, easy availability of medical information in the social media and consumerism has increased the additional number of issues discussed during a patient physician meeting. Inability to satisfy the patient or their families due to poor communication skills of physicians remains an universal challenge all over the world. Poor patient physician communication decrease patient compliance to treatment strategies, poor patient satisfaction scores and on the extreme lead to violence directed to physicians. Most medical schools and residency programs have incorporated patient-physician's communication skills in their curriculum. Similar opportunities to improve communication skills are available for practicing physicians. There are numerous tools that can be readily incorporated to improve the quality of patient physician communication. Communicating remotely with patients in the new era of COVD-19 using telehealth technology needs development of new skills that can be easily taught. Every physician need to periodically assess their own communication skills, and seek out conferences and learning opportunities within their hospitals, state, national or international medical community to continue learning and practicing new communication skills.

Full text

Journal of The Association of Physicians of India ■ Vol. 68 ■ June 2020 53
Eective Patient-Physician Communication – A Concise Review
Aditya K Ghosh1, Shashank Joshi2, Amit Ghosh3
13rd year Medical Student, St George’s University School of Medicine, Grenada; 2Dean, Indian College of Physicians; Consultant
Endocrinologist, Lilawati Hospital, Bhatia Hospital, Apollo Sugar Clinic, Mumbai, Maharashtra; 3Professor of Medicine, Mayo Clinic
College of Medicine and Sciences, Rochester, Minnesota, USA
Received: 10.05.2020; Accepted: 18.05.2020
REVIEW ARTICLE
Introduction
Any approach on the topic on
patient physician communication
should start with understanding of the
definition of the complex environment
where the communications take place,
i, e., healthcare, the uniqueness of
medicine as a service industry and
the expectations of the patient of their
physicians. Healthcare is often defined
as comprised healthcare systems and
the various actions and policy within
the system which improve health or
well being.1 A system based approach
of assessing care includes looking at the
structure of healthcare, examining the
processes involved in giving actual care
and the outcomes which results from
the consequence of the interaction of
the patient with the healthcare system.
While excellent communication is
involved in every step, it is most vital
during the process of delivering care.
Medicine is a service industry
however medical services are different
from other services.2 Unlike the ‘want’
services like telecommunication and
entertainment industry, healthcare is a
“need,’ service. Patient’s (consumer of
medical service) are under considerable
stress. Medical services are highly
complex and technical and patients are
at a considerable disadvantage due to
the lack of knowledge on the disease.
Most patients thereby have to trust their
physician to be their care providers
unequivocally.
In the healthcare environment,
patients are challenged emotionally
and go through physically grueling
procedures and the stakes are usually
high for patients. Errors in diagnosis,
treatment plan or procedure can do
great harm to the patient and worsen
their quality of life. Hence most
patients have to place an implicit trust
on their physician. This makes patient
seek physicians who possess high
interpersonal qualities.
There has been considerable debate
over years as what constitutes an
ideal physician behavior? Based
on a qualitative study of telephone
interviews of 192 patients seen in
the different medical specialties in
Mayo Clinic Scottsdale, Arizona and
Mayo Clinic Rochester, Minnesota
between the years 2001 to 2002, the
ideal physician was felt to be confident,
empathetic, humane, personal,
respectful, forthright, and thorough.2
Physician behavior was felt to be as
important as their technical skills and
could reflect on patients first perception
of physician competence. Emanuel
and Dubler3 have suggested that the
ideal physician-patient relationship
includes 6 C’s- Choice, competence,
communication, compassion, continuity
and (no ) conflict of interest.
The processes of delivering care
include interactions that occur between
the patient and the healthcare system
and comprises of (i) clinical care
and (ii) interpersonal care1. While
clinical care involve the biomedical
aspect of medicine and requires the
physician to be skilled at diagnosing
and treating the illness, interpersonal
care require the interaction of the
patient with the physician or other
health care provider and require skills
like communication, building trustful
relationship, honesty, respect, integrity,
empathy, and compassion.
In the present review we will focus
on patient-physician communication
with its challenges in clinical medicine
especially in India and elsewhere.
We will review the standard tools
that can enhance patient physician
communication in clinical practice
and describe educational methods
used in training of medical students
and physicians in the area of patient
physician communication. We highlight
knowledge and skills required to
communicate with patients using
Abstract
Current medical care is heavily reliant on the use of evidence-based guidelines
dealing with diagnosis and therapy. The burgeoning medical literature, easy
availability of medical information in the social media and consumerism has
increased the additional number of issues discussed during a patient physician
meeting. Inability to satisfy the patient or their families due to poor communication
skills of physicians remains an universal challenge all over the world. Poor patient
physician communication decrease patient compliance to treatment strategies,
poor patient satisfaction scores and on the extreme lead to violence directed
to physicians. Most medical schools and residency programs have incorporated
patient-physician’s communication skills in their curriculum. Similar opportunities
to improve communication skills are available for practicing physicians. There
are numerous tools that can be readily incorporated to improve the quality of
patient physician communication. Communicating remotely with patients in the
new era of COVD-19 using telehealth technology needs development of new skills
that can be easily taught. Every physician need to periodically assess their own
communication skills, and seek out conferences and learning opportunities within
their hospitals, state, national or international medical community to continue
learning and practicing new communication skills.

Journal of The Association of Physicians of India ■ Vol. 68 ■ June 2020
54
telehealth. This is of great relevance as
we need to communicate and manage
patients with chronic medical disorders
during the COVID-19 crises.
Challenges of Patient Physician
Communication
Recent innovations in diagnostic
medicine and availability of newer
treatment options have increased the
scope and opportunities of patient
physician communications abound in
developed countries. However many
medical leaders have lamented over
the slow progress of communications
skills in physicians which seem to lag
behind the tremendous advances in
scientific knowledge. Levinson and
Pizzo4 reported that there may be
2 major factors affecting physician-
patient communication.
1. Effective communication needs
the physician to be an active listener and
spend time with patients. Physicians
need to listen to their patients stories
and how the illness affected their
patients life. Active listening takes time
but can yield essential clues about the
patient’s health. Doctors are under
tremendous pressure to be productive
as required by the practice. In the
hospital practices there are frequent
handoff in transition of care which
makes time for connection with patients
challenging.
2. Many medical school and
residency programs provide inadequate
education on effective communication
skills. Lot more time is devoted in
teaching courses on advances in science
and technology as well as learning
evidence-based guidelines. In pre-
clinical years students are able to spend
time learning the curriculum as well
as taking part in OSCE’s. However
when students enter their clinical years
communication skills are not addressed
real-time in the locations where they
see the patient. Observation of students
when they examine patient’s in the
clinics or hospital setting and providing
with timely and specific feedback on
the pattern of communication that they
had with their patient is lacking in most
medical schools skills
In a study of videotaped interactions
of patient physician communication,
Fossum and Arborelius5 identified
several components of a favorable
patient centered consultation.
These include for (i) the provider
to be flexible, and (ii) being able
to frequently move back and forth
between discussion and communication
with the patient’s problems keeping the
patient’s expectation and concern into
account. Consultations that included
a steady, slow, sequential movement
through the topics were associated with
poor patient satisfaction as these did
not involve patient’s input and there
was a perception halfhearted attempt
for a shared decision making
Patient centric interviews and patient
physician communication
One the most common mistaken
notion is that every physician is the
skilled communicator.6 Most patients
presume that a technical sound doctor
is also an expert communicator. They
are disappointed many times as a
result of this assumption. Like most
disciplines in medicine, excellent
communication is a learned skill
that is not intuitive though can be
mastered with practice. The skill to be
an effective communicator is a lifelong
learning experience which needs
continuous practice and improvement
throughout the physician’s career. For
most physicians good communication
is also a good business practice.6
From the patient’s perspective it is
widely believed that patient centric
communication is preferred over a
physician centric communication style
when it comes to history taking. Patient
centered communication has a positive
impact on several important outcomes
like patient satisfaction, their adherence
to treatment recommendations, and
self-management of chronic diseases7.
Patient centered communication
increases the health providers
understanding of patients individual
needs, their values and perspectives,
and allows them to give to the patient
the information that they need for
their own care, to build trust and
understanding between the patient
and the physician. This pattern of
communication involves both verbal
and nonverbal of physicians (e.g.,
posture, eye contact, vocal tone).
Clinical outcomes in the management
of diabetes, hypertension, and cancer
are improved in patients who have
had a chance to communicate the
problems clearly by the physician
using a patient centric communication
style. Breakdown in communication is
associated with increased likelihood
that patient will initiate malpractice
actions,
National Cancer Institute lists six
fundamental functions of physician
patient communication namely, (i)
foster healing relationship, (ii) asking
and exchanging information, (iii)
responding to patients emotions, (iv)
managing uncertainty,(v) making
informed decision, and (vi) enabling
patient self management.8
Tools to Improving medical
communication skills
The common myths about doctor
patient communication is that
these skills are intuitive, innate,
and automatically learned by more
experience.9 Communication skills can
be learnt and improved. Physicians need
to devote time throughout their career
as communication skill is a lifelong
learning endeavor. Communication
needs to be thoughtful and measured
as words uttered in haste cannot be
retracted and have an adverse effect
on patients. What we say and how
we communicate has a placebo effect
(reduce anxiety) or nocebo effect (that
is bad communication can increase
pain and anxiety)! Patient’s values their
physician’s communication skills and
consider them equal or greater than any
cool technical skills. These also affect
the patient’s ratings of the care they
have received in hospital.
Many tools have emerged to aid in
doctor patient communication.
A. The medical interview process
can be conducted using the pneumonic
GREAT, LAURS and VALUE technique.9
i. GREAT : Greeting and Goals/
Rapport/ Evaluations, Expectations,
Examination and Explanation/ Ask,
Answer, Acknowledge/ Tacit agreement
and Thanks.
ii. LAURS : Listening, Acceptance,
Utilization of appropriate word,
Reframing, and Suggestion.
iii. VALUE: Value family statements,
Acknowledge emotions, Listen,
Understand a patient as a person, Elicit
questions. VALUE technique can help
in shared decision-making.
B. Relationship building skills can
be enhanced using PEARLS technique.10
PEARLS include Partnership for
joint problem-solving, Empathetic
understanding, Apologies for barriers
to learners success, Respect for patients
values and choices, Legitimation of
feelings and intentions, and Support

Journal of The Association of Physicians of India ■ Vol. 68 ■ June 2020 55
for efforts at correction.
C. Patient centered interview could
include the sentence ‘what else’ which
would let the patient to express all
the concerns rather than interrupting
patients after the first statement11
D. Assessing patients understanding
of medical problem can be performed
using the ‘Ask Tell Ask’ technique 12.
The ‘ask tell ask’ method includes the
following steps:
i. ASK the patient to describe the
current understanding of the issue this
will help the provider understand the
patient’s level of knowledge, emotional
status, and degree of education.
ii. TELL the patient in a simple
language what you need to communicate
regarding diagnosis, bad news, or
treatment options while avoiding
giving long lectures speak on easy
language languages
iii. ASK the patient if she/he
understood what you just said. This
will give you an opportunity to check
the patients understanding of her
problem
E. When things are not clear-
one effective technique that is used
commonly when things are not clear
or when you’re stuck is to ask for more
information using ‘Tell me more!”
F. Communication tools used while
responding to emotions - Use the
pneumonic NURSE13
i. N -Naming the emotion
ii. U -Understanding that the
patient’s feelings are problems. This
helps and building a relationship
iii. R -Respecting. Praise the
patient for strength. This this can be
a non-verbal response involving facial
expression, touch or change in posture
but could also be a verbal response
acknowledging and respecting the
patients emotions that shows empathy
iv. S- Supporting. Position can
express concern, willingness to help,
suggest statements about partnerships.
Acknowledge patients efforts to cope
v. E -Exploring and asking the
patient to elaborate on the emotion.
This puts the physician in the patient’s
position and to communicate that you
understand their situation.
Empathy is different from sympathy
which is a feeling of pity or concern
from outside the patient’s position
G. One strategy of breaking bad
news involves communication step
summarized by the six step pneumonic
SPIKES14
SPIKES stands for Setting,
Perception, Invitation, Knowledge,
Empathy, Strategize14. The six- step
protocol for delivering SPIKES include:
i. Setting: plan ahead and have
appropriate personal and family
members present. Anticipate for
possible patient reaction,
ii. Perceptions: as the patient what
he or she has been told about the
disease and audit the purpose of
meeting. Correct any misconception
iii. Invitation find out how much
the patient wants to know and how
was your she would prefer to hear
information
iv. Knowledge: gift patient the
news use small sentences without
medical jargon use pauses to address
any emotion.
v. Empathy use empathetic statement
to address emotions. Resist temptation
to fix the situation.
vi. Strategize emphasize what can
be done. Shift hope to achievable goals.
The key feature is maintaining hope
is to support the patient through the
grief and to re-orient them to what is
more achievable. Understanding what
is most important to the patient or what
the patient is most afraid of when they
are faced with the new medical reality
helps the patient grasp their situation.
An important aspect of communication
with patient is advanced care planning,
the process of finding out from the
patient the future goals of care as
disease worsens, and identifying a
surrogate decision maker.
What is the patients coping style?
Monitors versus Blunters
It is important to know your patient’s
coping style. Are they monitors or
blunters? Patients who have a problem
focused coping style are called monitors,
patient who use emotion focused
coping’s are called blunters.15
Monitors are more concerned and
distressed about the risk for disease
including cancer. They tend to scan
and amplify worrisome cues in their
health information and worry about
threats and risk for a long period of
time. They experience great anxiety
about health risk and keep worrying
about threatening information. While
dealing with patients who are monitors
it is important to provide them with
detailed information about the health
risk or this specific condition as well as
strategy of managing and reducing the
risk to decrease the anxiety.
On the other hand blunters do not
seek for detailed information about the
health risk of their medical condition.
They become overwhelmed with health
information. They find large quantity
of information to be stressful specially
if it includes statistics and risk factors
and therefore blunt or block it from
their conscious thought. Blunters may
avoid medical screening procedure
or choose not to engage in important
health behaviors depending on how
health information is presented and
interpreted by them. Effective health
messages presented to blunters should
be short and succinct. Physicians should
utilize non threatening language and
explained the course of action in simple
terms.
Can communication skills be taught?
1. Experiences with practicing
Physicians: Communication skills can
be taught to practicing physicians10. A
communications skill building course
for physician has been conducted
twice annually since 2004 in the
Mayo Clinic Arizona. These courses
where designed to increase physicians
personal awareness as well as allow
them to develop new communication
and interpersonal skills. Satisfaction
data from 3,561 patient surveys of 80
physicians who attended this course
were analyzed. Patients who were seen
by physicians who had completed the
course reported a higher satisfaction
rate as compared to the baseline scores
of these physicians. There was also a
18% decrease in patient complaints.15
The topics that were included in this
course where, (i) active listening and
reflection, (ii) eliciting and negotiating
an agenda and (iii) relationship
building. These topics were covered
with a combination didactics and
role-playing simulation. Participants
shared challenging experiences and
have opportunity to engage in role-play
simulation, followed by facilitator
guided debriefing. All participants
offered their perspectives and strategies
to each other when they encountered
similar situations. Facilitators noted
a increased spirit of continuous
learning and improvement. Physicians
where encouraged to incorporate the
appropriate skills and behaviors which

Journal of The Association of Physicians of India ■ Vol. 68 ■ June 2020
56
they found more useful for the practice.
2. Experience with medical students:
Medical students communication
skills at the Mayo Medical School is
assessed using a validated Interview
Rubric comprising of 13 items.16 Each
item under the category carry a score
of 1-4 assessing the thoroughness of
completion of each task under each
category. The Interview Rubric is used
to observe and provide feedback to
medical students during history taking
sessions of standardized patient’s..
The 13 categories of the Interview
Rubric are:
1. Introduction: An effective
introduction lessens the patient’s
anxiety. The initial first few minutes
of patient physician interaction is very
helpful informing a strong foundation,
2. Eye contact with the patient:
The provider’s eyes should be at the
same level with the patient’s eyes. A
consistent engagement on the part of
the provider is necessary as it shows
good listening capability.
3. Nonverbal communication :
Demonstration of emotions of physician
(student) through nodding off the head,
posture, body position, gives patient
an impression that the provider is
interested and empathetic
4. Listening. Not being listened is a
major source of patient to satisfaction.
Good listening skills and essential for
patient provider relationship.
5. Questions: Use simple language
in asking questions from the patient
instead of using complex medical
jargon. Clarify rather than simplify the
patient’s problems to help the student
come to a diagnosis.
6. Wait – time: Allow enough time
for the patient to answer one question
before going to the next question.
Giving inadequate time is disturbing
to patient.
7. Concern: Showing genuine
concern for patients problems and
interest in every patient
8. Organizations: Interview should
be conducted in an organized manner.
It doesn’t mean that it should be rigid
9. Information gathering: Establish
a list of the patient’s agenda for the
visit. Determine according to the
time available and the urgency of the
patient’s visit.
10. Focus: Interrupt the patient as
little as possible. However a subtle
control over the flow of the direction of
the interview is important to facilitate
the discussion.
11. Empathy: Ability to understand
the patient’s feelings and put his/
her feelings into words is essential
in Medicine. Demonstrating
empathy is essential part of effective
communication
12. Awareness of unspoken issues:
Gently probing and reading between
the lines when necessary can frequently
allow the physician gain significant
medical information hence watching
the patients emotions and concerns that
light below the surface of conversation
is important
13. Closure: An appropriate closure
to the interview is important. The
physician needs to summarize what
was discussed. It is necessary to ensure
to the patient that there are no pending
issues.
Communication in Telehealth era: The
COVID-19 experience
The nature of the Coronavirus
Disease 2019 (COVID-19) pandemic
has forced the medical practice to
evolve rapidly in order to adapt to the
new requirements. One of the most
notable adaptations recently has been
the relationship between patient care
and telemedicine has been one that
has slowly evolved over the years.
While in recent years, the practice of
telehealth has been evolving slowly,
it was still not considered plausible
that telehealth could be practiced
effectively. However, COVID-19 has
forced that plausibility to quickly
become a reality in order to safely
practice social distancing and to deliver
effective clinical care while avoiding
unnecessary face to face exposures
between doctors and their patients.
Even whilst the kinks and drawbacks
of telehealth are being discovered and
worked through, the practice is being
put to use by medical practitioners
around the world.
Telehealth, also known as
telemedicine, is defined as the
dissemination of medical information
that is conveyed through the medium
of electronic communication. The
modalities of this electronic
communication comprise of a wide
variety of resources including e-mail,
video chat, phone calls, remote
wireless monitoring, and mobile apps.17
Tuckson, et. Al,17 in their seminal paper
mentioned that there are three core
levels at which telehealth is practiced:
1) Clinician to Clinician, 2) Clinician to
Patient, and 3) Patient to Mobile Health
Technology.
At each level, the tools that are
utilized to practice telehealth and
the services that most often utilize
these tools are unique. For example,
clinicians will communicate to each
other via the use of e-mails and videos,
especially in settings of Emergency
trauma, ICU care, and surgical peer
mentoring.17 In these settings, it is
important for clinicians to be able
to communicate via video in order
to see examples and establish visual
connection regarding the care that
needs to be provided. Clinician to
patient telehealth is practiced in the
setting of care for chronic conditions,
medication management, mental health,
and counseling. In this setting, many
modalities of telehealth utilized include
remote wireless monitoring, as well as
video chat and phone calls.17 In these
settings, the connection outside of the
clinic or hospital setting is important to
cultivate via telehealth modalities, as it
allows for patients to routinely follow
up with their doctors without having to
schedule multiple visits, which could
discourage effective patient follow-up.
It also allows physicians to monitor
how their patients are improving over
time, or if there are changes that need
to be made to the management plan
in order to more effectively treat their
conditions (1). The last core setting
for telehealth involves the patient’s
connection to mobile health technology.
This is a very unique and growing
field, as it is a way of empowering
patient’s to become knowledgeable
of their own well-being in real-time
and to be a part of the process of self-
monitoring for signs of improvement.
The services that utilize this type of
telehealth include diet monitoring,
real-time fitness monitoring, and
overall health education. These mobile
health technologies are expanding
in number and method by the day
and include such devices as wearable
monitors, smartphones, and mobile
apps on the phone and tablet that can
provide evidence-based advice on
what areas of health the patient needs
to improve.17
All three of this core telehealth
settings (clinician-clinician, clinician-
patient, and patient-mobile health
technology) work together to guide
patient care and management.
Understanding the multiple avenues
and opportunities to incorporate
telehealth into medical care will help
in developing systems that can serve
as a powerful force in preventative
medicine, improve patient care, and
promote overall patient well-being.
As important as these benefits

Journal of The Association of Physicians of India ■ Vol. 68 ■ June 2020 57
are, it is important to explore the
drawbacks of telehealth practice as
well. A thorough understanding of
where telehealth can be seen as inferior
to a proper visit to the clinic can help
improve the overall experience of
the Doctor-Patient relationship while
conducting a Telehealth visit. Details
of the critical components of effective
telehealth visit are included in Table 1.
Effective communication with the
patient can drastically improve the
overall experience of telehealth practice
by using the techniques GREAT9 and
NURSE 13 discussed before.
These drawbacks include: 1) set up,
2) skill set is foreign to many healthcare
workers, not a developed skill set,
3) lack of management of the whole
environment, 4) anxiety management
(importance of building connection
with patient, knowing how to position
oneself in camera to not look down at
patient)
In conclusion patient physician
communication is among the most
essential lifelong skills for every
physician. Every physician need
to periodically assess their own
communication skills, and seek out
conferences and learning opportunities
within their hospitals, state, national
or international medical community
to continue learning and practicing
new communication skills. Every
physician needs to be aware of
their own communication styles
and the prevalent culture within
the community where they see their
patients. Communication skills needs
to be modified based on the subtle
cultural variation that exists between
different communities. Communicating
remotely with patients in the new era of
COVD-19 using telehealth technology
needs development of new skills
that can be easily taught. Mastering
good communication skills could be
one of the most satisfying personal
achievements for every physician.
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Table 1: Critical components of an Eective Telehealth Visit
What is it How is it conducted eectively
Environment I. Lighting
II. Background noise (either patient
or doctor)
III. What is behind the physician in
the background
Ensure that light is in front of face not
being the head, if windows in room,
ensure that light is on face or close the
windows.
Physician should also be aware of the
room that they conduct the telehealth
interview, and that it is appropriate
for the nature of the visit.
Vocal variety I. Tone while speaking
II. Clarity of voice
Physician should make sure to speak
with the patient in an engaged fashion
in order to foster the connection
with the patient. Also important to
ensure that the computer microphone
is appropriately capturing the
conversation, as technology should
not lead to miscommunication.
Condentiality Assurance that communication is
done over a secure line that will not
leave patient vulnerable to violation of
their privacy.
Working with hospital administration
to ensure that the service that the
telehealth is performed with will
maintain patient condentiality.
The physician’s use of headphones
will also ensure that the patient’s
discussions are not heard by anyone
else other than the physician.
Lag in response Faulty internet connection can lead to
a delay in response to answers.
Importance of patience during
technical diculties.
Lack of immediacy moving
from interview to executing
management
Upon conclusion of the Telehealth
interview, patient’s can feel like the
ball does not get rolling as quickly
as it does if they had just gone to an
in-clinic visit instead
Acknowledging patient concerns
while also eectively ensuring that the
patient’s management is not delayed
as much as possible. Explaining to
patient when it is not possible.
Aitude to unfamiliarity Easy for both physician and patient to
become frustrated with the unfamiliar
interaction, making it all the more
important that the appropriate
aitude is utilized during telehealth
communications.
Eective communication partnered
with a positive aitude towards the
dynamic situation can help improve
the overall experience that comes
when conducting a a telehealth visit.
Ensure that both sides are aware of
the unfamiliar, and mutually agree to
work together to cross those hurdles.
Equipment I. Web Camera
II. Microphone
III. Internet connection
IV. Adjustable height to make sure
webcam is at eye level
V. External lighting (optional)
Test out the webcam and observe how
the image appears, ensure that the
camera is at eye level by propping
the computer up with books or using
an adjustable chair. Important to not
appear to be looking down at the
patient when possible, as having the
camera at eye level best simulates the
regular in-clinic visit
Appropriate assignment of
purpose of telehealth visit
When entering into a telehealth visit,
similar to a regular in-clinic visit,
both doctor and patient should have a
shared understanding of the purpose
of that specic visit.
Before the telehealth meeting is
started, it is important that the
physician communicates with
the patient at least one day prior,
explaining the purpose of the
telehealth visit, in order to optimize
the discussion and keep it focused.
It is also important so that there is
not miscommunication regarding the
content and context of the discussion
that will be conducted during the
Telehealth visit.