As more hospitalized medical patients are cared for by hospitalists, both the patient and the physician are challenged to develop an effective patient-physician relationship. Hospitalists usually meet their patients for the first time at admission and care for them for a limited time before handing off care to a colleague. The challenges created by this situation can lead to poor outcomes and decrease the patient’s trust in the hospitalist and, potentially, the hospital. Communication skills can help hospitalists overcome these barriers by ensuring a clear exchange of information that engenders patient trust.
Research in the 1990s documented that communication and the patient-physician relationship are potent predictors of whether patients decide to file medical malpractice claims.1 In a review of The Doctors Company’s closed claims from 2005 to 2010, communication was noted as a risk management issue in 40 percent of the cases.
Incomplete communication during the initial assessment and during the hospital course can cause or contribute to poor patient outcomes. The patient’s presenting symptoms or medical history may not be completely elicited, or the doctor may not present information in a clear manner. These issues can compromise the patient’s ability to understand and adhere to the treatment plan. In addition, patients who do not trust their physicians or feel that the physician does not care about them are more likely to file claims, even if there is no negligence.2
A model of patient-centered communication can be used to address the issue of developing effective communication and a healthy patient-physician relationship (Figure 1). Key tasks in the model are eliciting patient concerns and addressing both informational and emotional aspects of the concerns.3 Eliciting and responding to patient concerns is associated with higher patient satisfaction.4
When patients arrive at the hospital, they have preexisting concerns they want to discuss with their doctors.5 These concerns are relevant to each patient’s hospital and follow-up care, being most frequently about medical diagnoses and treatments, logistics of care, prognosis, and symptoms.6 Patient-centered communication draws out these concerns and presents medical information in a relevant context. The patient’s concerns can be informational, revealing a question or lack of knowledge; for example, “I don’t know much about the treatment of pneumonia” or “How long will I be in the hospital?” The concerns may also disclose emotional distress; for example, “I’m worried about my daughter” or “I’m feeling vulnerable.” Eliciting and responding to both types of patient concerns is important.
Though most patients present with more than one pre-visit concern, many patients’ concerns are not addressed.7 Concerns may not be elicited because the physician doesn’t inquire about them, or the physician may interrupt the patient before he or she can finish describing the issue.8 Physicians may also assume that patients have only one concern. If information is not presented clearly, patients may report that their concerns are not addressed. Physicians frequently miss and, thus, do not address emotional aspects of concerns.9
Table 1 summarizes key skills for eliciting concerns and responding to information and emotional aspects. Eliciting concerns should be done at the beginning of the visit using an open-ended question. When the patient discloses a concern, the physician should acknowledge it. The physician can then inquire about the patient’s other concerns, a technique called “emptying.” Usually patients have no more than three concerns.10 If there are a high number of concerns, the physician and the patient can set an agenda prioritizing the concerns that are most pressing for the patient and leave the others for another time.11
Next, the physician addresses and responds to the informational and emotional aspects of the patient’s concerns. The “Ask-Tell-Ask” technique ensures that relevant information is given and received by bracketing each piece of information with a question to the patient. This technique focuses first on the information to be given and then on ensuring it was understood.12 To respond to emotion, physicians should show empathy: Acknowledge the emotion, provide respect and support, and explore the source of the patient’s distress. The acronym “NURSE” (Name-Understand-Respect-Support-Explore) describes empathic responses that physicians can provide.13 Though physicians may worry that responding to emotion will take too much time, it is not associated with longer visit lengths, and as little as 40 seconds of empathy can increase patient satisfaction.14 15
Eliciting and addressing patient concerns builds rapport and increases patient understanding and adherence. Learning key skills to develop an effective and satisfying patient-physician relationship is an important step for physicians in decreasing the likelihood of medical malpractice claims and increasing positive patient outcomes.
By Wendy G. Anderson, MD, MS, Assistant Professor, Division of Hospital Medicine, University of California, San Francisco.
This article originally appeared in The Doctor’s Advocate, third quarter 2011 (www.thedoctors.com/advocate).
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.