How to improve doctor patient communication

When I was a medical student on my first clinical rotation, obstetrics, I was criticized for not using enough medical jargon when I spoke to the patients.

I took that criticism as a compliment and have always attempted to speak clearly and without too much “inflation” of my terms. In my opinion, the more clearly we physicians communicate, the better will be our patients’ understanding of their ailments.

The important topic of doctor-patient communication led a neurosurgeon on iMedExchange, Dr. Thomas Lansen, to make some suggestions, which I have paraphrased and amplified below:

  • Don’t talk science to your patients. It may show what you know, but it doesn’t give them any information. Use language that is appropriate to the situation. Make real-world analogies.
  • Cover your important information slowly. If the clock is your enemy, invite your patient to return for questions at another visit.
  • Don’t be defensive. Most negative posturing by patients is a reflection of fear. Kindness and empathy help soothe people’s fears.
  • Patients forget what you tell them. We all do when we go to the doctor’s office. Repeat key elements and gently ask whether the patient understands the information.
  • A patient’s companion can be quite helpful. Treat questions from the companion with as much attention as if they came directly from the patient.
  • Don’t rush through negative information. When speaking about complications, give a few moments for questions, and be candid.  Complications don’t occur often, but if you have one, it’s a 100% occurrence for you; so it’s important that you know what could happen.
  • If you are a specialist, as I am, know that you may often encounter patients who have been referred from their physician who do not fully understand the implications of their disease. Work through this benign ignorance and help the patient come to a better understanding of the facts and details.

There are many more comments one could make, but let these few items serve as an addition to the topic of improving doctor-patient communication. That street goes both ways of course. It is important for both doctors and patients to understand each other’s points of view, as best they can, to ensure maximum understanding through information sharing. This aspect of being an e-patient is, to me, one of the most important: improved care through shared understanding.

Paul Dorio is an interventional radiologist who blogs at his self-titled site, Paul J Dorio, MD.

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  • http://www.medicallessons.net Elaine Schattner, MD

    You raise some good points about jargon.

    But some doctors take this too far, talking down to patients, which can be insulting. Avoidance of the command tense might help, too.

  • http://advocateyourself.blogspot.com Cheryl Handy

    Thank you for the post. Very nice discussion & I agree with your points.

    My thought is that the best physician-patient relationship is one of mutual respect. It is very easy for the physician to get in a pattern of first “eliciting” and then “communicating” information to the patient. We patients share stories and laugh at docs who told us to return to clinic and then in a robotic voice say “what brings you to see me today”? (Umm, you doc. You told me to come back in 6 weeks.)

    Patients want to trust their doctors and patients really want to believe that their doctors give a hoot about them. In other words, I just want my doctor to talk to me as if he actually liked me as a person. (No, I am not going to stalk you, doctor. And I do not expect you to invite to your home for dinner. I just know that you are more likely to care about whether I live or die if you like me as a person.) It might take an extra 15-20 minutes for the doctor to sit with me and engage me in a conversation. But if the doctor engages me and gets to know me then at least 3 purposes are served:

    1. The doctor will actually have a better sense of whether I understand what I was told. A dialogue beats a lecture any time.

    2. I will be a better, more compliant patient.

    3. I will be much less likely to sue you. Similarly, I will be much less likely to bother your staff or you.

    • Maribel

      I don’t expect my doctor to “care” about me just like I don’t expect my plumber to “care” about me. I just want the benefit of his knowledge and experience regarding my problem. Getting to know a little about a patient’s life may be helpful in treating the whole person but expecting doctors to like and personally care about all their patients is expecting too much (some patients may not be all that likeable!) That is what family and friends are for.

    • http://offwhitecoat.wordpress.com The Scrivener

      “It might take an extra 15-20 minutes for the doctor to sit with me and engage me in a conversation.”

      Yes, and that’s exactly why physicians don’t. Fifteen to twenty minutes isn’t a lot of time in the real world, but for a private practice physician — a small business owner — that’s two lost patient encounters. There’s a strong financial incentive, at least in private practice, to see as many people as possible (upwards of 30/day), because office rent and nurse/receptionist salary and malpractice insurance and educational debt wait for no one.

      In most cases, your doctor would like to spend time getting to know you as a person, not a set of lab values. But the financial disincentive is so strong that it’s a remarkable physician — or a boutique practice — that is able to do so.

      • http://advocateyourself.blogspot.com Cheryl Handy

        The Scrivener

        A physician who will not take the time to talk with a patient is setting himself up to have
        1. an unhappy patient
        2. a noncompliant patient (and thus unfavorable resolution of any medical problem)
        3. a lawsuit

        Physicians are going to have give a little. And if that means spending more time with patients then so be it. Patients do not like to be herded in and out like a cow. We are people not commodities.

        I am a small business person and I take plenty of time with each customer. That ensures the customer will be happy and come back!

        • jsmithfan

          If that customer took up an inordinate amount of time and you lost money with every interaction you had with that customer, would you still be going out of your way to spend all the time that customer expected from you. I think not. As a small business person, I would expect you to understand that running a doctors office is a business as well. Primary care docs work in a broken system that does not reimburse on time/caring/thoroughness/expertise. We are ONLY paid by volume of visits IN PERSON, IN THE OFFICE. Believe it or not, we hate it even more than you do. As a group, general internists and family medicine docs are the most selfless, compassionate, and empathetic physicians in the business. That’s why we get abused and dumped on all the time… because for some reason, we put up with it. The only currently implemented answer for the ever-increasing doctor-patient antagonism is the polarizing concierge model. But I’m going to guess that you don’t feel your PCP is worth $100 a month for her/his undivided attention and time. You expect endless time and resources and get upset when you don’t get it for your $20 copay. I wish you were the exception. Unfortunately, this is the general rule of current patient entitlement and lack of understanding in how the medical industrial complex works. It’s not even your fault, I don’t expect you to understand how screwed up everything is. But let me assure you, it’s FUBAR!!

        • http://offwhitecoat.wordpress.com The Scrivener

          I’m sorry; I don’t think I was clear in my initial response to you. Physicians — always excepting the occasional jerk who exists in medicine just as in every other profession — do want to “give a little” and spend that extra time with patients. Not just because of customer service/bring the patient back, but also because the barrage of modern medicine leaves physicians feeling just as shell-shocked as the patient. One of the reasons I decided against primary care was that I realized I was not ok with the time pressure I experienced during that rotation, which leads to very superficial encounters.

          Plus, the waiting room has more patients, who are going to be understandably upset if the doctor is running late. Ideally, everyone could be scheduled for a 30+ minute visit with no double-booking, but as jsmithfan points out, that’s financially not feasible aside from concierge practices.

          The challenge for physicians is to accomplish the personal level of the encounter in just a few minutes. I’ve been advised to do things like sit on my hands (to avoid taking copious notes), and Dr. Dorio’s suggestions here will help a great deal, I’m sure. I know that we have a long way to go, but believe me, we’re trying.

  • Paul Dorio

    Thanks for your comments. Great points from both readers. The list is by no means complete. Additions are of course welcome!

  • http://advocateyourself.blogspot.com Cheryl Handy

    Your body and health cannot be equated to your toilet.

    The patient absolutely should expect the physician to care about the patient’s health and well being. That is presumably why they are physicians. Why would I take life & death advise from a doc who didn’t care about me as a person?

    I do not believe that a doctor can effectively treat a patient the doc doesn’t like. Sometimes personality clashes prevent a successful pt-physician relationship. It is human nature.

  • http://healthpager.com Healthpager

    This is a great post. I too witnessed the same stuff on my first clinical rotation.

  • http://www.cancer-network.org liz margolies

    I especially appreciate your use of the word “companion”, understanding that patients’ support systems are made up of people with whom they may not have a legal attachment. For lesbians, gay men, bisexuals and transgender men and women (LGBT people), this is most often the case.

    Further, I would recommend asking patients about their support systems, who their “family” is, who will help with follow-up care, who should be in the room during hard discussions. Research shows that when LGBT are invited to bring their WHOLE selves into healthcare by a caring provider, they are more likely to engage with the healthcare system. As it stands now, LGBT people delay and avoid the health care system, including missing important cancer screenings, because of feared discrimination and previous negative experiences.

    I cannot over-emphasize the importance of cultural competence training for all health care providers. It may be the single largest thing we can do to decrease the health disparities of LGBT people.

  • Angel Brana

    Excellent opinion! On the other hand this has always been true and will always be true! Why then is it that we insist in speaking jargon? I would argue that as a “professional guild” we learn to monopolize knowledge (medicine in particular) to control the economic niche of it! Plain and simple!

  • C. McKinney

    I believe its important for a physician to be a more educated teacher and counselor with medicinal bonuses. lol.. I want the physician to take a few minutes to get to know ME, not my illness, but ME.. I have to be able to trust the person taking care of me, especially if I get worse, and just because a person has a license to practice medicine doesn’t mean they have the best intentions for me. I appreciate open communication with my physicians.. Don’t treat me like a child, shoot me straight, but also don’t be sarcastic with me just because I’m wary about believing what you say. There are just as many doctors who mean well as there are doctors who are there for the paycheck only. It’s like any other business, take care of me, and I’ll start referring more business your way. Treat me how you would want your doctor to treat you.

    • Angel Brana

      McKinney…
      I cannot agree more with your comments! For all that you say I feel proud of being a physician and will always be. Unfortunately that type of MD we’re talking about is not what our system prizes! We insist in talking that medicine is ALSO a business and most frequently the also is not even forgotten)…

      We have commodified medicine in such a way that the humanistic part of it (I would argue the most important because it is what allows me to “understand” the ailing person behind its illness) does not exist any more! All the talk about cultural competence, listening, being empathic… I’m afraid is “lip service” or simple self deception.

      See, in average a pt visits an MD 4-6 times a year and in average the encounter lasts 6-12 minutes… Imagine now the maximum of these values: Each single patient in the U.S. visiting an MD 6 times/yr, each time for 15 minutes… NOW, do you really think any one could get decent care (managing whatever illness one brings, including risk assessments, counseling, etc etc in 1.5 hrs a year! Are we kidding?

      I’m sorry my friends… In the U.S. we are in the game of self deception trying to convince ourselves that we have the best health care system in the world!

      Still you might remember the radical conservatives disturbing town meetings very recently on health care reform yelling “Don’t mess with my health care”… “I want my country back!”

      Perhaps the irony with this last phrase is true! They want the country back… to the middle ages!

      Angel

  • Lisa Martin

    I spend time explaining some complex topics to patients, without using a lot of medical jargon. Most patients can understand quite a bit when a subject is explained, and I think this understanding increases compliance. I do discuss pathophysiology, and even randomized controlled trials, when we have them, and when we don’t, and how this information can help us make decisions in the patient’s care. Patients appreciate the information and the extra time, but I can explain atrial fibrillation in 1 1/2 minutes, including the AFFIRM trial.

    • Angel Brana

      My friend… You must have brilliant patients!

  • http://advocateyourself.blogspot.com Cheryl Handy

    Angel Brana:

    If you are a proud doc who thinks “… In the US we are in the game of self deception trying to convince ourselves that we have the best health care system in the world,” you are overdue for a vacation or chat with a good mentor.

    I was one of those “radical conservatives” who organized mtgs w US Congressmen & docs. The docs said “Don’t mess with … health care”… “I want my country back” Those docs want health care reformed to a time when docs & pts liked each other and pts weren’t just a commodity.

    If you as a doc do not think pts are getting decent/adequate care where you practice then you are ethically obligated to protect pts & speak up. “First do no harm.”

  • http://www.healthecommunications.wordpress.com Steve Wilkins

    Communications is a two-way street. Both patients and physicians have a role in improving the quality of the doctor-patient dialog. There are some simple, evidence-based strategies taht any busy physician can incorporate into their practice.

    1) Invite patient participation right up front in the waiting room. Invite questions. Believe it or not, few patients ask “important questions” out of fear of interrupting, being pushy or sounding stupid.
    2) Let the patient complete their opening statement without interruption or immediately switching from opening statement to medical history and assessment.
    3) Ask the patient what they want to accomplish at “today’s visit.” Then negotiate your agenda with the patient to make sure both parties agendas are covered (at the present or subsequent visit).
    4) Get to know and honor your patient”s beliefs, motivations and previous experiences. Remember, most communications issues arise between patient and physician as a result of lack of concordance on key issues.

    For more information on physician-patient communications check out my blog Mind the Gap at http://www.healthecommunications.wordpress.com

    • Angel Brana

      Cannot agree more!

    • JustADoc

      One reads about allowing patients to talk uninterrupted at the beginning of a visit on all kinds of patient advocate sites. So I tried it. Occassionally it is useful but the most typical ‘open-ended’ statement was something along the lines of ‘My foot hurts’
      **crickets**
      **crickets**
      ‘Well can you tell me a little more about the foot pain?’
      ‘It just hurts. What’s wrong with it?’
      **crickets**
      **crickets**

  • http://drpauldorio.com Paul Dorio

    Great discussion. Thanks for the many comments and different perspectives.

    In my opinion, no matter how brief and time-limited, it is our obligation as doctors to try to effectively communicate appropriate information to our patients. It is equally important that patients attempt to reciprocate. Since I can’t control how well patients communicate with ME, I try to do my best to keep up my end of the bargain and impart information as clearly as possible.

    “Brevity is the soul of wit.”

    There is no excuse for not trying our best. Obviously, there are system limitations. Despite that fact, patients will benefit from and appreciate our attempts to clearly communicate relevant information.