Doctor-Patient Communication: A Review

INTRODUCTION

“Medicine is an art whose magic and creative ability have long been recognized as residing in the interpersonal aspects of patient-physician relationship.”1

A doctor's communication and interpersonal skills encompass the ability to gather information in order to facilitate accurate diagnosis, counsel appropriately, give therapeutic instructions, and establish caring relationships with patients.2–4 These are the core clinical skills in the practice of medicine, with the ultimate goal of achieving the best outcome and patient satisfaction, which are essential for the effective delivery of health care.5,6

Basic communication skills in isolation are insufficient to create and sustain a successful therapeutic doctor-patient relationship, which consists of shared perceptions and feelings regarding the nature of the problem, goals of treatment, and psychosocial support.2,7 Interpersonal skills build on this basic communication skill.2 Appropriate communication integrates both patient- and doctor-centered approaches.4

The ultimate objective of any doctor-patient communication is to improve the patient's health and medical care.2 Studies on doctor-patient communication have demonstrated patient discontent even when many doctors considered the communication adequate or even excellent.8 Doctors tend to overestimate their abilities in communication. Tongue et al9 reported that 75% of the orthopedic surgeons surveyed believed that they communicated satisfactorily with their patients, but only 21% of the patients reported satisfactory communication with their doctors. Patient surveys have consistently shown that they want better communication with their doctors.2

The principles of patient-centered medicine date back to the ancient Greek school of Cos.10 However, patient-centered medicine has not always been common practice. For example, in the 1950s to 1970s, most doctors considered it inhumane and detrimental to patients to disclose bad news because of the bleak treatment prospect for cancers.11,12 The medical model has more recently evolved from paternalism to individualism. Information exchange is the dominant communication model, and the health consumer movement has led to the current model of shared decision making and patient-centered communication.6,7,13–15

BENEFITS OF EFFECTIVE COMMUNICATION

Effective doctor-patient communication is a central clinical function, and the resultant communication is the heart and art of medicine and a central component in the delivery of health care.7,8,16 The 3 main goals of current doctor-patient communication are creating a good interpersonal relationship, facilitating exchange of information, and including patients in decision making.4,7,11,17 Effective doctor-patient communication is determined by the doctors' “bedside manner,” which patients judge as a major indicator of their doctors' general competence.1

Good doctor-patient communication has the potential to help regulate patients' emotions, facilitate comprehension of medical information, and allow for better identification of patients' needs, perceptions, and expectations.4,7,17 Patients reporting good communication with their doctor are more likely to be satisfied with their care, and especially to share pertinent information for accurate diagnosis of their problems, follow advice, and adhere to the prescribed treatment.1,6,7,9,14,16,18–23 Patients' agreement with the doctor about the nature of the treatment and need for follow-up is strongly associated with their recovery.10

Studies have shown correlations between a sense of control and the ability to tolerate pain, recovery from illness, decreased tumor growth, and daily functioning.16,20,24 Enhanced psychological adjustments and better mental health have also been reported.6,10,16,25,26 Some studies have observed a decrease in length of hospital stay and therefore the cost of individual medical visits and fewer referrals.1,27

A more patient-centered encounter results in better patient as well as doctor satisfaction.1,5–7,9,13,15,18,19,22,25,26,28–30 Satisfied patients are less likely to lodge formal complaints or initiate malpractice complaints.1,5,9,19,22,28 Satisfied patients are advantageous for doctors in terms of greater job satisfaction, less work-related stress, and reduced burnout.4,26

THE PROBLEMS

There are many barriers to good communication in the doctor-patient relationship, including patients' anxiety and fear, doctors' burden of work, fear of litigation, fear of physical or verbal abuse, and unrealistic patient expectations.31

Resistance by Patients

Today, patients have recognized that they are not passive recipients and are able to resist the power and expert authority that society grants doctors.35 They can implicitly and explicitly resist the monologue of information transfer from doctors by actively reconstructing expert information to assert their own perspectives, integrate with their knowledge of their own bodies and experiences, as well as the social realities of their lives.35 Being attentive to social relationships and contexts will ensure that this information is received, and most importantly, acted on.35 Lee and Garvin35 asserted that inequality, social relations, and structural constraints may be the most influential factors in health care. This was illustrated in their study when female patients from a lower socioeconomic demographic in the Appalachian region of the United States modified advice to avoid sun exposure and, by taking into account societal pressures that equated tanned skin with beauty, continued tanning despite knowledge of the risks associated with sun exposure and skin cancer (Figure). The study by Lee and Garvin35 demonstrates the need to take into account social factors in the production, dissemination, and use of knowledge.

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Example of influences that a patient takes into account on the doctor's advice.

STRATEGIES FOR IMPROVEMENT

LIMITATIONS AND FUTURE DIRECTIONS

Clinical research will guide improvements in determining best practice. Randomized controlled trials are able to effectively control bias and chance in evaluating efficacy. However, this is easier said than done in terms of investigations of communication. A majority of the studies reported in this review were cross-sectional.7 However, doctor-patient relationships are frequently long term, involving multiple visits, and this may limit the generalizability of the studies.

The approaches used in assessing doctor-patient communication and health outcomes in the literature are shown in the Table.7,30 Behavioral and observational components involve recordings to evaluate the actual medical encounter and analyze it in order to code behavior based on one of the observational instruments with respect to task and socioemotional behaviors.7,14,30 The patients' perception measures are assessed via surveys to rate frequency, occurrence, or other elements of physician behavior.7,14,43 Patients' perceptions may have a greater impact on their own outcomes than physician behavior, but their perceptions are subjective and subject to bias, and patients may be influenced by other factors such as their health status and state of mind and may not accurately reflect the reality of the consultation.7

Comparisons between studies are difficult as numerous tools are available but no single tool is completely satisfactory. Different studies use combinations of different tools for this reason. In addition, items are generated for measurement of patient perceptions without predefined categories of doctors' behaviors.7

Qualitative measures, although difficult to gauge, can provide a deeper understanding of patients' subjective perceptions. Clinically the most easily quantified outcomes are physiological measures, but these may not be possible in many surgical or chronic illnesses.19 They are also highly specific and may contribute minimally to an understanding of the patient's overall health.19 Satisfaction is a complex notion with many determinants and is used as the ultimate outcome of the delivery of health care services as it is a proxy for health, and its rating provides useful information about the structure, process, and outcomes of care.21,44 Morss et al, as quoted by Alazri and Neal,21 reviewed 21 relevant qualitative studies and found that the domains used to assess patient satisfaction with care included availability of the physician, coordination in a multidisciplinary team, competence, communication and relationships, ability to provide information and educate patients, responsiveness to emotional needs of patients, ability to provide holistic care, and ability to support patients' decision making. Satisfaction contributes to better medical outcomes through fulfillment of patients' values and expectations.21 Patients who experience good processes and outcomes of care are more satisfied and therefore more likely to continue maintaining the existing doctor-patient relationship.21

The main independent predictors of satisfaction have been patients' perceptions of communication and partnership, and a positive doctor approach.27 Satisfaction strongly predicts compliance with treatment and medical outcomes in acute illness.27 However, its use in medical interviews to relate to patient-centeredness may be inaccurate as its scales include subscales on communication.27

A majority of the literature frequently uses patient satisfaction and adherence to determine the efficacy of the doctor-patient relationship.7,39 The ability to generalize is limited, depending on, among other things, the size and representative nature of the specific population studied.7,36 Satisfaction needs to be investigated with a tightly defined and homogenous case mix to explore cause and effect of various factors on doctor-patient communication.27 In addition, the Hawthorne effect (awareness that one is being observed and evaluated) is difficult to avoid in observational studies and may affect behavior.5,45

CONCLUSION

“The patient will never care how much you know, until they know how much you care.” (Terry Canale in his American Academy of Orthopaedic Surgeons Vice Presidential Address9)

Doctor-patient communication is a major component of the process of health care.46 Doctors are in a unique position of respect and power. Hippocrates suggested that doctors may influence patients' health.19 Effective doctor-patient communication can be a source of motivation, incentive, reassurance, and support.19,47 A good doctor-patient relationship can increase job satisfaction and reinforce patients' self-confidence, motivation, and positive view of their health status, which may influence their health outcomes.19,47

Most complaints about doctors are related to issues of communication, not clinical competency.9,29,42 Patients want doctors who can skillfully diagnose and treat their sicknesses as well as communicate with them effectively.32

Doctors with better communication and interpersonal skills are able to detect problems earlier, can prevent medical crises and expensive intervention, and provide better support to their patients. This may lead to higher-quality outcomes and better satisfaction, lower costs of care, greater patient understanding of health issues, and better adherence to the treatment process.29,32 There is currently a greater expectation of collaborative decision making, with physicians and patients participating as partners to achieve the agreed upon goals and the attainment of quality of life.32