Hugh E. Mighty

The provider—patient relationship is a complex and dynamic one with several characteristics that differentiate it from other human relationships. It is a relationship in which the physician historically has been assumed to possess most of the expertise and authority. Until the last couple of decades, it was expected that the provider would use this expertise and authority to make decisions for the patient, and patients were expected to follow medical recommendations.

With the advent of the Internet and other readily available sources of medical information and advice, as well as the increased focus on patient-centered care, the provider— patient relationship has shifted away from this paternalistic model. Rather, it has become an increasingly consumer-driven model of care, in which patients are also viewed as having expertise and authority, many of whom expect to be actively involved in most decisions regarding their care. This new model presents both opportunities and challenges to interactions between health care providers and their patients.

This chapter reviews the core values and principles that should guide provider—patient interactions, and discusses the critical role of effective communication in prompting positive provider—patient interactions. It also explores some common challenges to effective interactions between health care providers and their patients.

Pellegrino identifes six virtues that are “indispensable for attainment of the ends of medicine”:

1. Fidelity to trust
   
2. Benevolence
   
3. Intellectual honesty
   
4. Courage
   
5. Compassion
   
6. Truthfulness

Effective communication is the foundation upon which the provider—patient relationship must be built. Providers must learn how to both elicit from their patients key information that helps guide diagnosis and communicate back to patients information on their diagnosis and treatment options in a way which can be comprehended and trusted. Providers who can master the skills of effective communication with their patients are more likely to have patients who are satisfied with the care they receive, who are more compliant with treatment recommendations, and who are less likely to sue for an unanticipated outcome.

Results of numerous research studies suggest that patients who have a positive relationship with their health care provider are more likely to have improved health outcomes. The recognition of the importance of both communication and interpersonal skills, and of the fact that these skills can be taught, has led accrediting and licensing entities, including the Accreditation Council for Graduate Medical Education (ACGME), to include these skills as a core competency.

Eliciting All Pertinent Information From a Patient at Interview

Gathering information from the patient is a critical component of each provider—patient encounter. The patient can provide key data regarding symptoms that can help guide diagnosis, information about individual circumstances that can affect disease progression and likelihood of treatment success, and information regarding side effects and symptom improvement, worsening, or resolution that may help the provider monitor the success of the treatment and/or management plan.

The process of information sharing by the patient is facilitated if the encounter is patient-centered rather than clinician centered. Unfortunately, too many clinical encounters are guided by, and focus on, the provider. One study found three common features of such provider-focused care: 1) Clinicians do a majority of the talking even when they are obtaining a history; 2) They ask nearly six closed-ended questions for every one open-ended question; 3) They often interrupt the patient when he or she is trying to provide information or ask a question.

Not giving patients adequate time to be heard or not letting them provide other pertinent information can be particularly dangerous, since the patient often has information that is critical to a timely diagnosis. In addition to knowing how to listen and what questions to ask and when, the clinician must know how to ask questions in a way that will maximize the chances that the patient will share complete and accurate information.

The provider must be especially sensitive to the choice of words as well as any body language that may interfere with the patient’s willingness to share information. This is especially important in the field of obstetrics and Gynecology in which providers often need to ask about sensitive topics such as reproductive choices and sexual activity—topics about which most patients will be hesitant and cautious to share information.

The patient may not fully understand why the provider needs this very private information. Therefore, when discussing such sensitive issues, it may be helpful to share with the patient the reason for the question, and help her to understand its relevance to her health.

For example, when asking whether a patient whether she has sex with men, women, or both, the provider can explain that certain conditions such as cervical cancer are most common among women who have sex with men. Or, when asking about a history of sexually transmitted infections, the provider can explain that Chlamydia or gonorrhea can cause a condition that can lead to infertility, or that a herpes outbreak during labor and birth can cause a dangerous infection in the newborn.

The provider should reassure the patient that the information gathered will be used to improve the care provided to her and will be kept confidential. Another helpful strategy to relieve patient anxiety regarding questions about sensitive topics, when relevant, is to “normalize” the question. In other words, the provider can let the patient know that the question is routinely asked of all patients.

The provider can even show the patient that these questions are written into the preprinted prenatal record. For example, questions eliciting a thorough history of gynecologic infections, including sexually transmitted infections, are a part of every routine first obstetric visit.

Although checklists and medical forms can help expedite health care encounters and ease documentation, they can also lead patients to omit information that may be important for the provider to know. The same situation can occur when providers ask questions that the patient can answer with a simple “yes” or “no” or other one-worded answers. These are called closed-ended questions. Such questions are sometimes necessary.

However, it is also necessary at times for the provider to elicit additional relevant information. Asking open-ended questions is a useful way to elicit such information. Some examples of valuable open-ended questions are as follows:

When the patient has provided any information, the physician can ensure that he or she has heard and interpreted this information correctly by asking additional questions for clarification and by stating back to the patient what was said. The following is an example of how this works: “Ms. Jones, if I understand you correctly, you feel that the IUD would be a good form of birth control for you, because you are pretty sure that you do not want any more children, but are not ready for a permanent form of birth control such as a tubal ligation. Is this correct?” “Furthermore, I hear you saying that you are worried about the cancer risks associated with hormonal methods of birth control. Is this correct?” “Are there any other concerns that might affect your choice of birth control method?”

The provider should make sure to ask such questions in a nonjudgmental tone of voice, using words that are easy to understand and avoiding medical jargon. When the patient is answering a question, the provider should refrain from interrupting her or from completing her sentences. Studies have shown that physicians interrupt patients in their opening statement in the vast majority of visits, when the patient has barely had time to talk about her health issues.

When providers interrupt in this manner, they run the dual risks of having the patient shut down and not share vital information and of “nontracking” the conversation, that is, shifting the focus of the visit to what the physician, rather than the patient, perceives to be relevant. As has been mentioned earlier, this can lead to delays in diagnosis or, even worse, to a misdiagnosis.

The physician’s body language during the encounter and his or her listening skills are equally as important as determining what questions to ask and how to ask them. Listening is an active form of communication. As Freeman summarizes:

“Listening is not simply hearing words. It involves a concerted effort to listen to the way the words are said, to recognize the feelings underlying the spoken word and to be aware of what the patient has left out of their narrative. This last aspect of listening has been called ‘listening with the third ear.”

Thus, the provider needs to be aware not only of what is being said, but of both his or her own body language and that of the patient’s. The provider should make ample eye contact with the patient—which is easier if the patient and the provider are at the same eye level (both sitting down, for example). Furthermore, although it is often necessary to take notes on the medical chart as the patient provides information, if the provider looks only at the chart and not the patient, he or she may miss some important nonverbal cues from the patient. It is also important to take a break from charting, if the patient is disclosing sensitive information or is upset or otherwise emotional.

In addition to putting down the chart and looking at the patient, leaning forward and nodding are other examples of body language that encourages the patient to share information. Physicians should avoid body language that gives the patient the message that they are in a rush or that the information being conveyed is not important. This negative body language includes standing up while the patient is talking, looking at a watch or clock, turning one’s back on the patient to chart, or standing next to the door.

Delivering Information to a Patient

Many of the same guidelines of effective communication discussed above apply as well to clinical encounters in which a provider needs to convey, rather than elicit, information. In these circumstances, however, the provider has the additional challenges of providing information in a clear manner, and then of ensuring that the patient has indeed understood the information being conveyed.