Communication Skills

When it comes to being a clerk, I consider myself pretty average. I keep up with my readings, know my patients pretty well, and generally put in a good effort into my clinical duties. However, I'm far from exceptional in any of these domains. Where I do consider myself a bit stronger is when it comes to communicating with patients and their families. I have plenty to learn and perfect on that front, but I'll put myself a bit ahead of the pack on that front.

I though I'd take a post to go through some of the basics of my approach to patient communication, as it's not something I feel is well taught or reinforced in medical education. I often see clerks, residents and staff committing some very basic errors when speaking with patients.

1) Establish rapport first, don't forget to maintain it

That having a good rapport with patients is critical to achieving optimal care with patients is no surprise to most medical students. It's an art - no two people will have the same method for achieving a good rapport yet drastically different approaches can be equally effective depending on the circumstance and the physician's personality. However, there are some basics to establishing and maintaining rapport which I've seen get forgotten, neglected, or perhaps never learned.

To start, taking 10-15 seconds at the beginning of an interaction for some simple pleasantries can go a long way. It's fine to get down to business quickly, but don't forget that your trust hasn't been earned just because you're a physician, and that first minute or two can make a world of difference. I try to work in a quick joke within that time if an appropriate opportunity arises - I find it puts people at ease far more easily than anything else. Most physicians understand this critical introductory period and do make an effort to come across as an actual human being for the first few minutes, though some are more effective than others, some use blatantly scripted approaches, and some forgo this entirely.

Where I see more stumbles is that once that initial phase passes, the physician's attempt to connect with patients disappears entirely. Once those pleasantries are completed, it's on to business, no time for things like emotions or empathy! This kills a lot of physician-patient relationships. Trust not only has to be earned, it has to be maintained. A few empathetic statements, jokes, or check-backs with the patient to establish understanding throughout the interaction are practically essential. They show that the patient is heard and that their presence is appreciated rather than simply tolerated.

2) Manage expectations

People will accept almost anything if they can prepare themselves for it. I've seen patients take news of a death sentence in stride because they knew it was coming before any words were spoken. The opposite is also true. People react very badly to surprises, even rather benign ones. Sick patients and their families, who may be emotionally and physically exhausted, are that much more prone to dealing with the unexpected poorly.

Medicine is inherently unpredictable. Doctors make educated guesses and can be pretty good at it, but very little is known with certainty. Good communication requires imparting some of that uncertainty to patients and their families. It's also vital to communicate exactly where that uncertainty lies. Are you uncertain because you don't know, or because you can't know? If you don't know, is it because you need input from a colleague, results from a test, or simply the time to let things play out?

Ultimately, the goal is to have their expectations be your expectations. You want your patients to hope for the best but plan for the worst, just as you will in your practice.

Being proactive is the key. Physicians frequently assume their patients are on the same page as them without confirming that this is the case. Taking 30 seconds to explain the plan, with considerations for how the plan might change and why, is an extremely important yet often neglected point of any patient interaction.

3) You're not all-powerful - don't pretend to be

Similar to the previous, be very clear about what is in your power and what isn't. Patients think doctors have a lot more authority and ability than we actually do. Physicians, sadly, tend to play into this myth. Fortunately, it's an easy trap to avoid.

Being clear about your role from the beginning is important, particularly for trainees. Never assume a patient knows what you can and can't do.

A major component of this is learning how to say "no" without it seeming like an exercise in power. The phrase I hear some doctors rely on which irks me so much because of the problems it causes patients (and other providers) is "I won't". A patient makes a request and the physician says "I won't do that". There is typically a good reason for the refusal and the physician either can't or shouldn't fulfill the request in the first place. Even with an explanation of the refusal, "I won't" sticks in patients minds, because they see the physician as being capable of helping, but actively choosing not to. It hurts a lot of patient-physician relationships. I like using "I can't" as much as possible, provided it's appropriate. Fortunately, most "I won't"s can be framed as "I can't"s. Patients are still disappointed by refusals presented this way, but I find they're less disappointed in me as a care provider, and that helps to maintain the therapeutic relationship a bit better. Physicians and patients have a natural imbalance, which patients certainly feel. By emphasizing your own lack of ability to change things with phrases like "I can't", it can help to lessen the feeling of that imbalance, and to make it clear that even if you aren't able to solve all their problems, you're still trying to do what you can.

4) Ensure you're on the same page

Even when a physician is an amazing communicator, patients don't always understand the full plan. Medicine is vast and confusing, even to the initiated. Human memory is flawed in healthy people and gets worse when we're sick or stressed. Letting patients know what's coming is only effective if they absorb what was said and remember it.

Some easy strategies can help retention. I frequently try to repeat whatever plan we agree on in a concise way at the end of an interview. I then provide an opportunity for questions, in case there are any points of confusion.

Even that leaves plenty of room for things to slip through the cracks. Two approaches I'd like to use more often - but have difficulty implementing as a learner - is having patients repeat back the plan and/or writing down the plan. At this stage, all my plans are tentative, subject to approval by my supervisors and, in many cases, subject to change without my knowledge. I can't pin down anything I say at the risk of having the patient remember my suggestions ahead of the attending physician's actual recommendations. I've already had at least one instance where this has caused trouble. So, for now, I've held off these strategies, but would like to implement them once I gain some more ability and independence.

None of the above elements are overly difficult to implement and with practice become second nature. However, they are not always intuitive, rarely taught, and virtually never reinforced in medical training. We could be doing a lot better to develop a culture of effective physician-patient communication.