Patient-Centered Communication: Basic Skills PDF

Patient-Centered Communication: Basic Skills M. JAWAD HASHIM, MD, United Arab Emirates University College of Medicine and Health Sciences, Al Ain, Abu Dhabi Communication skills needed for patient-centered care include eliciting the patient’s agenda with open-ended ques- tions, especially early on;...

Patient-Centered Communication: Basic Skills M. JAWAD HASHIM, MD, United Arab Emirates University College of Medicine and Health Sciences, Al Ain, Abu Dhabi Communication skills needed for patient-centered care include eliciting the patient’s agenda with open-ended ques- tions, especially early on; not interrupting the patient; and engaging in focused active listening. Understanding the patient’s perspective of the illness and expressing empathy are key features of patient-centered communication. Under- standing the patient’s perspective entails exploring the patient’s feelings, ideas, concerns, and experience regarding the impact of the illness, as well as what the patient expects from the physician. Empathy can be expressed by naming the feeling; communicating understanding, respect, and support; and exploring the patient’s illness experience and emotions. Before revealing a new diagnosis, the patient’s prior knowledge and preferences for the depth of information desired should be assessed. After disclosing a diagnosis, physicians should explore the patient’s emotional response. Shared decision making empowers patients by inviting them to consider the pros and cons of different treatment options, including no treatment. Instead of overwhelming the patient with medical information, small chunks of data should be provided using repeated cycles of the “ask-tell-ask” approach. Training programs on patient-centered com- munication for health care professionals can improve communication skills. (Am Fam Physician. 2017;95(1):29-34. Copyright © 2017 American Academy of Family Physicians.) T CME This clinical content he Institute of Medicine identi- Eliciting the Patient’s Agenda conforms to AAFP criteria fied patient-centered care as one Patient-centered medical interviewing should for continuing medical education (CME). See CME of six elements of high-quality begin with the introduction of all persons Quiz Questions on page 8. health care.1 A patient-centered present at the visit. This includes the physi- Author disclosure: No rel- approach to care is based on three goals1-3 : cian and the patient, and anyone else in the evant financial affiliations. eliciting the patient’s perspective on the ill- room, specifying their relationship to the ness, understanding the patient’s psychoso- patient. In nonurgent situations, positive cial context, and reaching shared treatment remarks about nonmedical issues such as the goals based on the patient’s values. Patient- weather, generalities about the day, or non- centered care builds on discussions and specific encouraging observations can help decisions that involve shared informa- build rapport. New patients should be wel- tion, compassionate and empowering care comed to the clinic. Avoid opening the inter- provision, sensitivity to patient needs, view with “How are you feeling?” or “How are and relationship building.3 In contrast to you today?” because these questions may lead a disease-focused biomedical approach, the patient to somatize their concerns into patient-centered care considers patient physical symptoms.5 Instead, the open-ended preferences, needs, and values, ensuring question “How can I help you today?” brings that they guide all medical decisions in focus to the purpose of the visit, enabling tandem with scientific evidence.1 Although patients to discuss anything relevant to their most patients (about 70%) prefer patient- health, and emphasizes the physician’s role as centered communication, it is difficult to a helper. It is the preferred initial statement predict preferences for an interviewing for initial and follow-up visits.6 style (patient-centered vs. disease-focused) On average, physicians tend to interrupt a based on the patient’s age, sex, or ethnicity.4 patient within 16 seconds of asking an open- This article provides an overview of patient- ing question.7 Allowing patients to speak centered communication techniques for uninterrupted may take an average of just physicians. Table 1 outlines a sequence for six seconds longer than redirecting them.8 medical interviewing that incorporates More significantly, allowing patients to patient-centered elements. speak reduces late-arising concerns. Because January 1, 2017 Downloaded ◆ Volume 95, Number 1 from the www.aafp.org/afp American Family Physician website at www.aafp.org/afp.  American Academy of Family Copyright © 2017 American Physicians.Family Physician For the private, 29 noncom- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Downloaded for Anonymous User (n/a) at Griffith University from ClinicalKey.com.au by Elsevier on May 27, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. Patient-Centered Communication Table 1. Recommended Sequence for Patient-Centered Medical Interviewing Item Suggested phrases/comments Introduce and build rapport All persons present at the visit should be introduced. In nonurgent situations, positive remarks about nonmedical issues, such as the weather, generalities about the day, or nonspecific encouraging observations, can help build rapport. Elicit the patient’s agenda Avoid starting with “How are you feeling?” or “How are you today?” because these questions may lead the patient to somatize his or her concerns into physical symptoms. Instead, use phrases such as “How may I help you today?” or “What can I do for you today?” to bring the focus to the purpose of the visit. List all of the patient’s agenda items Ask the patient, “Is there something else?” until he or she replies in the negative. Negotiate the agenda Suggested phrases: “Which of these is the most concerning to you?” “I would also like to discuss your… today.” “Because we have limited time, which of these problems would you like to discuss today?” “I know… is important to you, and I am very concerned about your… Could we start with… first?” Start discussing the patient’s concerns Suggested phrases: with open-ended questions “Tell me more about…” “Would you like to talk more about…?” “I want to know how it started…” “Tell me what the… was like?” “What else did you notice?” Ask direct questions to elicit details Questions should address the duration, severity, and location of the problem; radiation and about the chief concern, and character of pain; relieving and aggravating factors; and any associated symptoms. perform a review of systems Elicit the patient’s perspective See Table 3. Empathize See Table 4. Summarize Suggested phrases: “So, from what you have told me so far, you…” “Let me summarize what we have discussed so far.” “You have told me a lot of things. Let me just say it out loud, so you know that I have heard you correctly.” Transition Suggested phrases: “Now I would like to ask you some routine questions. These may seem personal or unrelated but are important for us to help you.” “Now I would like to ask you some questions about your previous health.” Additional data Elicit information about medicines and allergies, medical history, and social and family histories (including social support network, interests, and spirituality). patients often present with more than one concern (on Patients can thus express themselves in an atmosphere average, 1.7 concerns per visit; range, one to four),9 physi- of nonjudgmental acceptance, often providing valuable cians should continue to ask “Is there something else?” diagnostic information that they may not provide with until the patient replies in the negative. Using the term closed-ended questions. Focused active listening by the “something” is more effective than “anything” in elicit- physician is critical at this stage, and distracting activi- ing concerns without increasing the duration of the visit.9 ties (e.g., reviewing the patient’s medical record) should Physicians may prioritize concerns based on patient be avoided while the patient is talking. Later in the inter- preferences and medical urgency. Low-priority concerns view, after the patient appears to have expressed his or can be deferred to a future visit. The primary concern her concerns, physicians can interleave the conversation should initially be explored using open-ended phrases: with brief reviews of the medical record. Documenta- “Tell me more about…” This should be followed by tion should be completed after the patient has left the a silent pause and, if needed, nonverbal facilitation. room. Table 2 includes examples of verbal and nonverbal 30 American Family Physician www.aafp.org/afp Volume 95, Number 1 ◆ January 1, 2017 Downloaded for Anonymous User (n/a) at Griffith University from ClinicalKey.com.au by Elsevier on May 27, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.  Patient-Centered Communication Table 2. Verbal and Nonverbal Methods for Facilitating Patient-Centered Communication Method Examples methods for facilitating patient-centered Verbal communication. Continuers “Go on,” “I hear you,” “Hmmm,” “Aha” Direct questions can elicit specifics Legitimation “That makes sense.” about the patient’s chief concern, includ- Open-ended questions “Tell me more about...” ing the duration, severity, and location of Understanding “It seems like …“ the problem; radiation and character of Exploration “I wonder if you …“ pain; relieving and aggravating factors; and Rephrasing “Let me summarize what you have told me so far…” any associated symptoms. This part of the Checking the patient’s “Could you summarize what we have discussed medical interview is often biomedical in understanding so far?” focus and assists in determining a working Nonverbal diagnosis. Additional questions are guided Attention Judicious eye contact by hypothesis-driven clinical reasoning as Responsiveness Facial expressions such as grinning, lip biting, the patient’s story unfolds and the differ- concerned frowning ential diagnosis is narrowed. Although the Attentiveness Holding of chin, keeping index finger on temple review of systems has traditionally been the Openness Palms exposed, avoiding crossed arms or legs Interest Leaning forward last item in the medical interview, it should Active listening Head nodding be obtained after the history of presenting Focus Purposefully turning away from the computer or illness because it can support diagnostic medical file reasoning. Tactful silent pauses Avoiding interrupting or completing sentences Understanding the Patient’s Perspective The patient’s views of his or her illness are a primary focus of patient-centered care. The Table 3. Phrases to Help Elicit the Patient’s Perspective patient’s perspective includes feelings, ideas, concerns, impact, and expectations. Asking Areas of focus Suggested phrases the patient about his or her understand- Feelings “How did that make you feel [emotionally]?” ing of the cause of the illness may provide “Tell me more about what was worrying you.” additional diagnostic clues. Understanding “What were your emotions at that time?” the patient’s beliefs allows the physician to “What would you say is worrying you the most?” appreciate the cultural context of the illness. “How do you feel about that?” Thus, physicians can avoid recommending “What was that like [emotionally]?” interventions that go against the patient’s Ideas “What do you think is the cause of…?” views. Table 3 includes phrases that can be “Do you have any thoughts on what might be causing this?” used to help in understanding the patient’s Concerns “What do you worry about regarding your health?” perspective. “Is there something you worry might happen?” Exploring the patient’s feelings is impor- “What are your fears about…?” tant in assessing the emotional burden and Impact “How has your illness affected your daily life?” psychological impact of the illness. Unex- “What difficulties are you facing because of your illness?” pressed emotions may impede the patient’s Expectations “What would you like to get out of today’s visit?” trust and confidence in medical care. Phy- “What more can I do for you today?” sicians should not judge the patient’s emo- “Is there anything else you need from us today?” tions as being appropriate or inappropriate and resist offering premature reassurance early in the medical encounter.10 Similarly, normal- of these fears may be unfounded or unlikely, requir- izing (“Many of my patients experience this” or “This ing gentle exploration and eventual reassurance. Other is a fairly common reaction”) without first adequately fears are realistic and require a thorough understand- exploring the concern may be perceived as blocking the ing of the patient’s values and resources. The patient’s patient’s feelings. fears may help the physician understand the patient’s Patients often have concerns about future complica- priorities in managing the disease. Physicians can thus tions and disability from their medical problems. Some ensure that the treatment plan addresses these concerns. January 1, 2017 ◆ Volume 95, Number 1 www.aafp.org/afp American Family Physician 31 Downloaded for Anonymous User (n/a) at Griffith University from ClinicalKey.com.au by Elsevier on May 27, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. Patient-Centered Communication An illness can impact a patient’s life in ways that the Revealing a Diagnosis physician may not anticipate. Discussion should explore Family physicians routinely have to inform patients the effects of the illness on personal activities and social about a new diagnosis, such as diabetes mellitus, her- responsibilities (e.g., the inability to care for oneself, loss pes infection, or cancer. Inappropriate communication, of employment). such as an abrupt or harsh disclosure, can be psycho- Physicians often do not accurately perceive patients’ logically devastating to the patient. Yet, there is limited expectations during visits.11 The patient’s expectations empirical evidence on communication techniques for may be medical (e.g., diagnosis; physical examina- breaking bad news.13 Patients prefer that physicians tion; medications, such as analgesics or antibiotics) or be seated when breaking bad news.14 Detailed infor- may include nonmedical requests, such as a note for mation is requested more often by patients who are sick leave. Some patients may state that they need reas- younger, female, and more educated.15 Recommenda- surance (after careful evaluation) more than medical tions for breaking bad news include first assessing the treatment. In such cases, prescribing an unwanted treatment will most likely be inef- fective. Patient-centered care respects the Table 4. Techniques for Expressing Empathy to Patients patient’s expectations without disregard- ing clinical evidence. Some requests need to Technique Examples (may overlap) be explored with open-ended questions to Naming “It seems like you are feeling…” find out the patient’s underlying concerns. “I wonder if you are feeling…” Examples include requests for unnecessary “Some people would feel… in this situation.” prescriptions or testing, such as antibiot- “I can see that this makes you feel…” ics for viral respiratory infections or brain imaging for tension headaches. Exploratory Understanding “I can understand how that might upset you.” statements include “I am interested in know- “I can understand why you would be… given what you are going through.” ing why…” or “Tell me more about why you “I can imagine what that would feel like.” would like…” “I can’t imagine what that would feel like!” Expressing Empathy “I know someone who had a similar experience. It is not easy.” Empathy is the capacity to understand and “This has been a hard time for you.” relate to the patient’s illness experience and “That makes sense to me.” emotions. Physicians can express empathy verbally or through nonverbal gestures, such Respecting “It must be a lot of stress to deal with…” “I respect your courage to keep a positive attitude in spite as respectful silence, touching a patient’s of your difficulties.” hand or knee (when culturally appropriate), “You are a brave person.” or sighing. In some situations, such as when “I am impressed by how well you handled this.” a patient is tearful, offering a box of tissues “It sounds like a lot to deal with.” is perhaps more appropriate than verbal “You have been through a lot.” expression. Table 4 includes techniques for “You did the right thing by coming in.” expressing empathy to patients.10 Physicians should recognize that their Supporting “I want to help in any way I can.” “Please let me know if there is anything I can do to help.” work has an element of “emotional labor.” “I am here to help you in any way I can.” Regardless of their own emotional state, “I will be with you in this difficult time.” physicians need to show concern and inter- “I will be with you all the way.” est verbally and through facial expressions.12 This can manifest as deep actions (with Exploring “Tell me more about what you were feeling when you empathic understanding) or surface actions were sick.” (displaying empathic expressions without “How are you coping with this?” full cognitive engagement). In contrast, “What has happened since we last met?” physicians who listen with an unresponsive, blank expression are in effect blocking the Information from reference 10. patient’s emotions. 32 American Family Physician www.aafp.org/afp Volume 95, Number 1 ◆ January 1, 2017 Downloaded for Anonymous User (n/a) at Griffith University from ClinicalKey.com.au by Elsevier on May 27, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.  Patient-Centered Communication SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Comments Physicians should avoid interrupting the patient early in B 7, 8 Observational studies the interview. Physicians should elicit the patient’s agenda early in the B 9 One randomized controlled trial interview until all concerns have been expressed. The phrase “Is there something else?” is preferred over “Is there anything else?” Training programs, even those of short duration (less than A 20, 23 43 randomized controlled trials 10 hours), generally improve physicians’ patient-centered communication skills. Training on patient-centered communication combined with B 20 Less than 20 trials with mixed results; effect disease-specific materials may improve patient outcomes. size was smallest for health outcomes Patient-centered care is an intrinsically desirable health care C 26 Expert opinion priority regardless of its effect on clinical outcomes. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort. patient’s prior knowledge and understanding of the ill- Final Comment ness, and the patient’s preference for an overview vs. Exploring and understanding the patient’s illness expe- detailed information. Important points to consider are rience and respecting the patient’s beliefs and expecta- included in Table 5.14,16 Patients should be given time to tions are at the core of patient-centered communication. absorb the news. Physicians should empathize with the Patient-centered communication should extend to patient’s emotions while limiting further information medical documentation by respecting patients as per- in this initial stage. sons. Terms such as “a case of” and “chief complaint” Shared Decision Making By discussing treatment options, physi- Table 5. Suggestions for Revealing a New Diagnosis cians can help patients make more informed or Breaking Bad News choices. The pros and cons of each option should be outlined, including benefits, risks Area of focus Suggestions (potential immediate and long-term adverse Setting Ensure privacy, avoid distractions and interruptions, involve effects or complications), and costs (direct significant others, sit down, and connect with the patient and indirect).17 The option of no active treat- (e.g., eye contact, touch if culturally appropriate). ment with follow-up (watchful waiting) may Perception “What do you already know about your illness?” be discussed. Providing options reaffirms “What is your understanding of the illness?” the patient’s need to be actively involved in his or her medical care.18 Invitation “How much information would you like to receive at this However, the patient should not be over- time?” “Do you prefer to receive the information in stages or all burdened with extensive information. A bal- at once?” anced approach involves asking about the patient’s previous knowledge of the illness, Knowledge “Unfortunately, I have some bad news.” then providing small chunks of information “I am sorry to inform you that…” and checking for understanding after each Use words that are familiar to patients. Avoid medical jargon. Do not be excessively blunt or insensitive. chunk (ask-tell-ask technique).10 The patient’s Provide information in small chunks and allow time values and goals should be explored if the for comprehension. Do not take away hope because patient is unable to make decisions based patients may have other, nonmedical goals. on medical information alone. The patient’s Emotions Respond to the patient’s emotions with empathy (Table 4). clinical condition, health literacy, and emo- tional state, and the complexity of the medi- Strategy Discuss treatment options, if the patient is emotionally cal decision may necessitate multiple sessions ready, to maintain hope and a future-oriented outlook. with the physician. Shared decision making can be supported by printed aids that visually Information from references 14 and 16. depict clinical risks using pictographs.19 January 1, 2017 ◆ Volume 95, Number 1 www.aafp.org/afp American Family Physician 33 Downloaded for Anonymous User (n/a) at Griffith University from ClinicalKey.com.au by Elsevier on May 27, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved. Patient-Centered Communication should be replaced with “a patient with” and “chief 6. Beckman HB, Frankel RM. The effect of physician behavior on the col- lection of data. Ann Intern Med. 1984;101(5):692-696. concern.” Training programs, even those of short dura- 7. Dyche L, Swiderski D. The effect of physician solicitation approaches on tion (less than 10 hours), have been shown to generally ability to identify patient concerns. J Gen Intern Med. 2005;20(3):267-270. improve physicians’ communication skills.20-22 However, 8. Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient’s patient-centered communication alone does not appear agenda: have we improved? JAMA. 1999;281(3):283-287. 9. Heritage J, Robinson JD, Elliott MN, Beckett M, Wilkes M. Reducing to improve patients’ health status or behaviors.23 There is patients’ unmet concerns in primary care: the difference one word can some evidence that adding disease management skills to make. J Gen Intern Med. 2007;22(10):1429-1433. training programs on patient-centered communication 10. Back AL, Arnold RM, Baile WF, Tulsky JA, Fryer-Edwards K. Approach- may improve patient outcomes.20 Observational studies ing difficult communication tasks in oncology. CA Cancer J Clin. 2005;55(3):164-177. indicate an association between patient-centered com- 11. Perron NJ, Secretan F, Vannotti M, Pecoud A, Favrat B. Patient expec- munication and patients’ trust in physicians,24 as well as tations at a multicultural out-patient clinic in Switzerland. Fam Pract. reduced diagnostic testing.25 Patient-centered care is an 2003;20(4):428-433. intrinsically desirable health care priority, regardless of 12. Larson EB, Yao X. Clinical empathy as emotional labor in the patient- physician relationship. JAMA. 2005;293(9):1100-1106. its effect on clinical outcomes.26 The following YouTube 13. Paul CL, Clinton-McHarg T, Sanson-Fisher RW, Douglas H, Webb G. Are videos provide assistance with patient-centered commu- we there yet? The state of the evidence base for guidelines on breaking nication: https://www.youtube.com/playlist?list=PLNfC bad news to cancer patients. Eur J Cancer. 2009;45(17):2960-2966. yzdWB9X6myvivDIeSofzZE0gosTN7, https://youtu.be/ 14. Bruera E, Palmer JL, Pace E, et al. A randomized, controlled trial of physi- cian postures when breaking bad news to cancer patients. Palliat Med. ekrnhvqmm-o, and https://youtu.be/36Cuuzw1p8w. 2007;21(6):501-505. Data Sources: A PubMed search was conducted using the term patient- 15. Fujimori M, Uchitomi Y. Preferences of cancer patients regarding com- centered communication. The search was refined using the Sort by Rel- munication of bad news: a systematic literature review. Jpn J Clin Oncol. evance and Related Articles features. The results were not limited by type 2009;39(4):201-216. of article, language, or date of publication. Additional sources searched 16. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. included the Cochrane database, EMBASE, ScienceDirect, EBSCO Aca- SPIKES-A six-step protocol for delivering bad news: application to the demic Search Complete, and Web of Science. Search dates: September patient with cancer. Oncologist. 2000;5(4):302-311. 13, 2015, through September 26, 2016. 17. Makoul G, Clayman ML. An integrative model of shared decision mak- ing in medical encounters. Patient Educ Couns. 2006;60(3):301-312. 18. Ngo-Metzger Q, August KJ, Srinivasan M, Liao S, Meyskens FL Jr. End- The Author of-life care: guidelines for patient-centered communication. Am Fam Physician. 2008;77(2):167-174. M. JAWAD HASHIM, MD, is an associate professor of family medicine at 19. Agoritsas T, Heen AF, Brandt L, et al. Decision aids that really promote the United Arab Emirates University College of Medicine and Health Sci- shared decision making: the pace quickens. BMJ. 2015;350:g7624. ences, Al Ain, Abu Dhabi. 20. Dwamena F, Holmes-Rovner M, Gaulden CM, et al. Interventions for Address correspondence to M. Jawad Hashim, MD, United Arab Emir- providers to promote a patient-centered approach in clinical consulta- ates University, Tawam Hospital Campus, P.O. Box 17666, Al Ain, Abu tions. Cochrane Database Syst Rev. 2012;(12):CD003267. Dhabi, 17666 (e-mail: [email protected]). Reprints are not 21. Maatouk-Bürmann B, Ringel N, Spang J, et al. Improving patient- available from the author. centered communication: results of a randomized controlled trial. Patient Educ Couns. 2016;99(1):117-124. 22. Boissy A, Windover AK, Bokar, et al. Communication skills train- REFERENCES ing for physicians improves patient satisfaction. J Gen Intern Med. 2016;31(7):755-761. 1. Institute of Medicine. Crossing the Quality Chasm: A New Health System 23. Epstein RM, Duberstein PR, Fenton JJ, et al. Effect of a patient-centered for the 21st Century. Washington, DC: National Academy Press; 2001. communication intervention on oncologist-patient communication, qual- 2. Epstein RM, Franks P, Fiscella K, et al. Measuring patient-centered com- ity of life, and health care utilization in advanced cancer: The VOICE ran- munication in patient-physician consultations: theoretical and practical domized clinical trial [published ahead of print September 9, 2016]. JAMA issues. Soc Sci Med. 2005;61(7):1516-1528. Oncol. http://oncology.jamanetwork.com/article.aspx?articleid=2551984 3. Constand MK, MacDermid JC, Dal Bello-Haas V, Law M. Scoping review (subscription required). Accessed September 26, 2016. of patient-centered care approaches in healthcare. BMC Health Serv Res. 24. Fiscella K, Meldrum S, Franks P, et al. Patient trust: is it related to 2014;14:271. patient-centered behavior of primary care physicians? Med Care. 4. Swenson SL, Buell S, Zettler P, White M, Ruston DC, Lo B. Patient- 2004;42(11):1049-1055. centered communication: do patients really prefer it? J Gen Intern Med. 25. Epstein RM, Franks P, Shields CG, et al. Patient-centered communication 2004;19(11):1069-1079. and diagnostic testing. Ann Fam Med. 2005;3(5):415-421. 5. Tongue JR, Epps HR, Forese LL. Communication skills for patient- 26. Berwick DM. What ‘patient-centered’ should mean: confessions of an centered care. J Bone Joint Surg Am. 2005;87(3):652-658. extremist. Health Aff (Millwood). 2009;28(4):w555-w565. 34 American Family Physician www.aafp.org/afp Volume 95, Number 1 ◆ January 1, 2017 Downloaded for Anonymous User (n/a) at Griffith University from ClinicalKey.com.au by Elsevier on May 27, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.