Patient-centred communication

• To be understood as individuals with their own specific values, beliefs, practices, goals, coping skills, and needs
• To be treated with respect, honesty, and dignity
• Culturally safe care
• Relief from pain and discomfort
• Competent, efficient, and empathic healthcare providers
• Help navigating the healthcare system
• Effective transitions in and coordination of care
• Acknowledgement by providers of the impact of the illness on patients’ lives
• Support for themselves and for family and friends who care for them⁵

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Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions. It is important to realize that patient may understand the same information differently.

Skilled communicators:

• use plain language
• check patients’ understanding frequently
• invite patients to voice their questions
• choose their words carefully
• provide printed information (handouts) and illustrations when possible⁶

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Although a patient may seem to understand the language spoken by the physician, if this is the patient's second or third language there may be gaps in understanding. In such circumstances, it may be appropriate to use a trusted interpreter to assist with language impediments.

If a translator is not available, you may ask a family member to translate (with the patient's permission). However, exercise caution when relying on friends or family members for this purpose, whose interpretation may be influenced by their own views of the discussion. For instance, a family member might be embarrassed to translate your questions about sexual activity, and the patient might be reluctant to reveal the truth.

Document the use of a translator, along with the discussion, in the medical record.

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Communication is more than just what is said. There may be a need to clarify issues when you see:

• hesitancy
• a change in tone of voice
• a new facial gesture
• a change in body language

Be mindful of your own non-verbal communication skills. Body language and behaviours such as these may unwittingly signal to the patient that they are not welcome to speak and may convey subtle disapproval:

• crossing your arms or legs
• using rushed speech
• tone of voice (rushed, condescending, upset, disapproving, disbelieving, etc.)
• looking at the computer screen or smartphone instead of the patient

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Respecting difference and diversity

Each patient may hold beliefs different from your own. Treating every encounter as potentially cross-cultural will help you recognize and respect cultural differences as well as enhance communication and foster a safe environment for the expression of these differences.

There are visible and non-visible aspects of culture. Visible aspects include language, dress, food and rituals. Non-visible aspects include perceptions of time, notions of modesty, reactions to physical space, and how emotions are managed. A patient’s culture may affect their interpretation of symptoms, coping skills, and approach to health, impacting their level of engagement in care planning, choice of treatment, and adherence to treatment.

Cultural differences may also influence how professional boundaries are perceived, and being aware of this may help prevent misunderstandings.

Physicians with an intercultural mindset try to understand other cultures and address issues that may interfere with the provision of good and safe care. This approach helps patients feel safe to express their preferences.

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Male, female, transgender, and non-binary patients may all experience discomfort with being examined by a physician, regardless of the physician’s gender. It is always a good practice to verify a patient’s comfort with a proposed physical examination and to seek their consent for the examination. Misunderstandings can be avoided by carefully explaining the reasons for potentially sensitive questions or physical examinations to patients.

Recognizing the importance of gender identity and gender expression is a key component of patient-centred care.  The simple act of staff asking patients about their preferred pronoun at registration can convey to patients that the office is a safe space and thus help patients feel accepted.

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Physicians have estimated that as many as 15% of patient encounters are difficult. Patients and physicians can both contribute to making an interaction challenging.

Anger

Anger is a secondary emotion. When patients are angry, it may reflect their fear of the diagnosis. Anger can also be a response to a particular situation like a long wait to be seen, a previous negative healthcare experience, the inability to see a consultant expeditiously, or feeling unheard or disrespected. Physicians can enhance the likelihood of a successful encounter by taking the necessary time to seek out the reason behind the anger and trying to address it.

Physicians too may become angry and defensive, especially if feeling stressed or even burnt out by situations beyond their control. Becoming aware of your emotions creates an opportunity to step back, reflect and take measures to restore balance. Learn more about physician support and wellness.

Manipulation

At times, physicians may get a sense that they are being manipulated. Manipulation can be a challenge; it can lead physicians to relent and provide questionable therapy when viewed in retrospect. In such circumstances, reflecting on your own emotional triggers arising from the interaction is a good first step to understanding the nature of the problem. It is helpful to attempt to understand the reasonableness of a patient’s expectations, recognizing it may be appropriate to stay firm in saying “no.” Obtaining a second opinion may help to reinforce appropriate therapeutic boundaries.

Attitude

Patient and physician attitudes may affect an encounter from its very beginning. Being mindful of one’s biases, triggers, and fervently held beliefs can be helpful to manage personality clashes. Shared decision-making requires a genuine desire to facilitate a patient’s ability to communicate their needs based on their desires and beliefs. Dogmatic stances and paternalism on the part of physicians may come across as arrogance and may inhibit a patient’s ability to provide important information.

Time and urgency factors

Health providers are frequently pressed for time. Often, patients may be unable to express their symptoms, signs or concerns concisely and patient-centered communication may need to be adjusted to accommodate individual needs. Quickly interrupting patients may seem necessary to control the agenda and it can become easy to take shortcuts or become complacent, especially at the end of the day. While they may seem to expedite interactions, interruptions are likely to adversely impact the quality of the physician-patient relationship.

Taking a purposeful approach of letting patients express themselves uninterrupted for the first few minutes may help build a sense of cooperation and engagement that may otherwise not happen with earlier interruptions.  Physicians who may be reluctant to allow patients to express themselves freely for fear of running over time may be reassured to know that studies have shown most patients will complete their narrative within 90 seconds.^7,8,9

Somatization

Somatization occurs when psychological or emotional distress is manifested in the form of physical symptoms that are otherwise medically unexplained. Patients with somatization may seek care from multiple physicians and may feel unheard or dismissed. They may have had many investigations in seeking an organic cause for their symptoms, which may instead have anxiety, depression, or other underlying mental health issues as a source. It is important that psychiatric diagnoses be identified and addressed and to resist the urge to order more tests, unless clinically indicated. While carefully reviewing the patient’s past care, be mindful of cognitive biases and affective biases that may interfere with reasoning and decision-making. Such biases may result in inaccurate judgments and the inability to reach a correct diagnosis. Special attention to follow up may help reassure patients, decrease their fears and allow for the monitoring of symptoms for clinically relevant changes.

Opioid seeking

Managing the care of patients on high-dose or long-term opioid therapy for chronic non-cancer pain is complex. This situation calls for a strategic, patient-centred approach that incorporates guidelines, validated tools, provincial and territorial resources, as well as support from a multidisciplinary team. Clinical practice guidelines such as the Guideline for opioid therapy and chronic non-cancer pain¹⁰ support appropriate prescribing to reduce associated harms. Regulatory authorities (Colleges) also offer guidance and direction. The Opioid Manager from McMaster University may also be useful as a point of care tool.¹¹

Fatigue

Both patient and physician fatigue have been shown to impact patient safety.¹² Setting boundaries, relinquishing over-commitment, and taking time for enjoyable personal and family activities contribute to physician health. Good nutrition and sleep habits are important. Managing your own health needs facilitates healthy interactions with patients.

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All physicians encounter difficult behaviour and conflict with some patients or patients' families. Despite the best of intentions, physicians cannot meet patient or family expectations all of the time. Conflict can arise when these expectations are not met.

Clear communication is essential to prevent or diffuse conflict.

• Verbalize your perspective clearly, using understandable language.
• Allow the patient or family member to state their perspective.
• Be open to questions.
• Seek clarification. Try to understand patients’ behaviour in the context of their overall life situation, mental health, and medical condition.

Patients’ expectations can be met—such as fulfilling a request for information, expressing compassion in the face of difficult circumstances, and showing respect during treatment—thus reducing the potential for minor irritants to be magnified into major challenges.¹³

Physicians have a professional responsibility to communicate professionally when disagreements with patient arise.

• Make sure you are safe. If you or others are at imminent risk of physical harm, leave and call for help.
• When no immediate risk of harm exists, keep calm.
• If required, move the patient to a quiet, confidential area.
• Position yourself so as to have easy access to the exit.
• Explain the facts and situation rationally.
• Offer possible solutions.
• Do not try to intimidate the patient or allow yourself to be intimidated.
• Assist your staff if they are confronted with an angry patient.
• If there is no way to resolve the issue, end the interview politely.
• Record the facts objectively and without emotional language.

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Common complaints to medical regulatory authorities (Colleges) include that the doctor:

• didn't listen
• was rude
• ignored a patient’s concerns
• discriminated against a patient^{14, 15}

To help foster a healthy physician-patient relationship and make appropriate determinations on time management:¹⁶

• Orient yourself to the patient by considering the following situational factors:
  • Is this a new relationship or an ongoing physician-patient relationship?
  • What type of problem does the patient have? (Minor or serious?)
  • What is the nature of the patient’s problem? (Acute, urgent or chronic?)
  • What are the needs of this individual patient? (e.g. health literacy, cultural needs)
  • Where is the consultation taking place? (office, clinic, emergency department)
  • What orienting information is available? (e.g. medical records, electronic medical record (EMR), handover notes )
• Watch for signals and cues from the patient that might indicate confusion, disagreement, or misunderstanding:
  • The patient’s body language (e.g. smiles and nods for understanding and looking away, shaking head) may signal disagreement.
• Seek confirmation of the patient’s feelings and provide opportunities for questions.
• Be careful about labels:
  • Do not use pejorative labels.
• Be careful of humour. Not everyone finds the same things funny or that it is an appropriate time for humour.
• Be sensitive that your assessment of the degree of a patient’s pain may not mirror the patient’s. Generally document the subjective experience as “the patient states their pain is …” as well as objective findings such as ease of movement, vital signs, absence/presence of tenderness, etc.

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Etiquette-based medicine simply means bringing politeness into the patient interview. Polite, courteous and respectful communication will go a long way to ensure communication remains as constructive as possible.

Even before asking about the patient's condition or feelings, remember to:

• Review the patient’s medical record before entering the room.
• Use a culturally appropriate greeting to show respect to the patient.
• Knock on the door before entering.
• Introduce and explain the presence of any trainees.
• Don’t assume the patient knows who you are or what your role is. Introduce yourself, explain your role in the patient’s care, and if you are a trainee state your level of training.
• Sit down.
• Face the patient.

Sensitive questions

Inquiring about sensitive topics like sexual activity, age at puberty and sexual function. may make many patients uncomfortable. Patients may not understand why you need to ask sensitive questions in the context of what they perceive to be a consultation for an unrelated concern. Taking the time to give clear, timely explanations of your reasons for asking sensitive questions may help avoid misunderstandings.

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• Take the time to establish rapport before beginning your assessment.
• Identify the reason for the visit.
• Allow the patient to explain their concerns without interruption.
• If it is necessary to interrupt the patient, do so professionally and compassionately e.g. excuse yourself, empathize with the topic, and explain the reason for interrupting.¹⁷
• Focus your attention on the patient, suspend initial judgment, and limit other mental activities.
• If possible, leave your phone on silent. Checking it during patient encounters may make the patient feel you are too busy or don’t care.
• Repeat back or paraphrase what was said to confirm your understanding and convey you’re listening.
• Maintain comfortable eye contact.
• Be mindful of body language.
• Make any notes unobtrusively.
• If you type as you go or refer to the medical record or EMR as the patient speaks, take the time to explain what you are doing. You may be interpreted as inattentive without such explanations.
• Where appropriate, share your screen with the patient and invite them to follow along with you, as a means of engaging them.

When used effectively, active listening allows people to open up, establish rapport, demonstrate concern, avoid misunderstanding, resolve conflict, and build trust. 

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Give clear, timely explanations of the reason for doing an examination and the nature of the examination—especially when conducting a sensitive or intimate examination.  Specifically, patients may not automatically understand why you may need to examine their genitals, anus, or breasts. To avoid misunderstandings and to ensure physical contact will not be misinterpreted, it is wise to take the time to seek express consent for such examinations.

• Consider and offer the use of a chaperone during intimate exams.
• Respect the patient’s right to privacy by providing appropriate draping and leaving the room when the patient dresses and undresses.

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Strong physician-patient relationships are built on trust. How physicians convey information is just as important as the information conveyed. Doing this well will help align patient expectations with treatment plans and foster adherence to treatment. 

It is possible to elicit the patient’s perspective to achieve a shared understanding by asking questions such as:

• Have we covered everything?
• Does your diagnosis make sense to you?
• Do you have some concerns we haven’t addressed?
• Will this treatment be difficult for you?
• What is the biggest challenge for you?
• How would you handle a complication should it arise?
• If you had to communicate this to your family what would you say? (teach back)

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Acknowledging your patient’s emotions conveys caring and understanding, even though you may not have time to deal with everything at that point.

• Set realistic expectations; do not falsely reassure.
• Sometimes the patient and/or family member may disagree or have other expectations.

One way to ensure that your patients feel heard is to explore their perspective using the FIFE mnemonic.

• Feelings – related to their illness, especially fears about their problem or illness
• Ideas - explanations about what is wrong or the cause for their illness.
• Functioning – impact of their illness on daily activities
• Expectations – of the encounter with their physician and of the treatment

FIFE may allow you to recognize that there could be unmet (or unrealistic) expectations and that they need to be managed or discussed with the patient.

Similarly, the BATHE technique allows the exploration of the patient’s experience of their illness.

• Background: “What’s going on in your life?”
• Affect: “How do you feel about it?” or “What has that been like for you?”
• Troubles: “What troubles (concerns, worries) you most about it?”
• Handling: “How are you handling (dealing with, coping with) it?”
• Empathy: “That must be difficult for you.”

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When leaving your care, it is important for patients to be well informed around their condition and the outcomes of the visit. Inform patients of the following facts to help them monitor their situation:

• the clinical situation and diagnosis (or differential diagnoses if there is uncertainty)
• symptoms and signs alerting them to seek further medical care (for example, how to recognize that the condition is worsening)
• where to seek care and how urgently it should be sought

The information should be tailored to each patient and clinical situation. This advice would include discussion of the potential side effects and monitoring requirements of any prescribed medication.

Just as when obtaining informed consent, it is important to describe the symptoms and signs of common complications and also of rare complications with a potential for serious harm. It is a good practice to confirm the patient’s understanding of the issues and address any questions and to document the discussion with the patient in the medical record.

The hand-on-the-door question

Despite a physician’s best efforts to set an agenda and identify key concerns to be addressed during the visit, patients may well take more time than allotted for their appointment. They may also ask the “one last thing” or “by the way” question which may be a new or unrelated problem that could be more urgent than what was otherwise discussed. In such cases, despite the risk to an on-time office schedule, it is important to remain courteous and open-minded.

Patients are unlikely to be able to identify which of their many issues is the most urgent to address. While it is not mandatory to address all issues in one visit, regulatory authorities (Colleges) generally discourage a “one issue per visit” policy. Rather, to foster safety, physicians should determine if the “last minute issue” requires an urgent or non-urgent response. Emergent issues need to be addressed immediately. For non-urgent issues, it may be helpful to reassure the patient that you have heard their concern and would like to take the appropriate time to address the issue at another visit.

• Asking patients to provide an overview of all their concerns at the beginning of the visit can help you triage matters, set an appropriate agenda for the available appointment time, and avoid the “hand-on-the-door” question.

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