Doctor-Patient Communication: A Review

Jennifer Fong Ha, MBBS (Hons) Dip Surg Anat and Nancy Longnecker, PhD

Abstract

Effective doctor-patient communication is a central clinical function in building a

therapeutic doctor-patient relationship, which is the heart and art of medicine. This is important
in the delivery of high-quality health care. Much patient dissatisfaction and many complaints are
due to breakdown in the doctor-patient relationship. However, many doctors tend to overestimate
their ability in communication. Over the years, much has been published in the literature on this
important topic. We review the literature on doctor-patient communication.

INTRODUCTION

Medicine is an art whose magic and creative ability have long been recognized as
residing in the interpersonal aspects of patient-physician relationship.

A doctor's communication and interpersonal skills encompass the ability to gather

information in order to facilitate accurate diagnosis, counsel appropriately, give therapeutic
instructions, and establish caring relationships with patients.4 These are the core clinical skills in
the practice of medicine, with the ultimate goal of achieving the best outcome and patient
satisfaction, which are essential for the effective delivery of health care.5,6

Basic communication skills in isolation are insufficient to create and sustain a successful
therapeutic doctor-patient relationship, which consists of shared perceptions and feelings
regarding the nature of the problem, goals of treatment, and psychosocial support.2,7
Interpersonal skills build on this basic communication skill.2 Appropriate communication
integrates both patient- and doctor-centered approaches.4

The ultimate objective of any doctor-patient communication is to improve the patient's

health and medical care.2 Studies on doctor-patient communication have demonstrated patient
discontent even when many doctors considered the communication adequate or even excellent.8
Doctors tend to overestimate their abilities in communication. Tongue et al9 reported that 75%
of the orthopedic surgeons surveyed believed that they communicated satisfactorily with their
patients, but only 21% of the patients reported satisfactory communication with their doctors.
Patient surveys have consistently shown that they want better communication with their
doctors.2
 The principles of patient-centered medicine date back to the ancient Greek school of
Cos.10 However, patient-centered medicine has not always been common practice. For example,
in the 1950s to 1970s, most doctors considered it inhumane and detrimental to patients to
disclose bad news because of the bleak treatment prospect for cancers.11,12 The medical model
has more recently evolved from paternalism to individualism. Information exchange is the
dominant communication model, and the health consumer movement has led to the current
model of shared decision making and patient-centered communication.6,7,13,15

BENEFITS OF EFFECTIVE COMMUNICATION

Effective doctor-patient communication is a central clinical function, and the resultant

communication is the heart and art of medicine and a central component in the delivery of health
care.7,8,16 The 3 main goals of current doctor-patient communication are creating a good
interpersonal relationship, facilitating exchange of information, and including patients in
decision making.4,7,11,17 Effective doctor-patient communication is determined by the doctors'
bedside manner, which patients judge as a major indicator of their doctors' general competence.1

Good doctor-patient communication has the potential to help regulate patients' emotions,
facilitate comprehension of medical information, and allow for better identification of patients'
needs, perceptions, and expectations.4,7,17 Patients reporting good communication with their
doctor are more likely to be satisfied with their care, and especially to share pertinent
information for accurate diagnosis of their problems, follow advice, and adhere to the prescribed
treatment.1,6,7,9,14,16, 18, 23 Patients' agreement with the doctor about the nature of the
treatment and need for follow-up is strongly associated with their recovery.10

Studies have shown correlations between a sense of control and the ability to tolerate
pain, recovery from illness, decreased tumor growth, and daily functioning.16,20,24 Enhanced
psychological adjustments and better mental health have also been reported.6,10,16,25,26 Some
studies have observed a decrease in length of hospital stay and therefore the cost of individual
medical visits and fewer referrals.1,27

A more patient-centered encounter results in better patient as well as doctor

satisfaction.1,5, 7,9,13,15,18,19,22,25,26,28, 30 Satisfied patients are less likely to lodge formal
complaints or initiate malpractice complaints.1,5,9,19,22,28 Satisfied patients are advantageous
for doctors in terms of greater job satisfaction, less work-related stress, and reduced burnout.4,26
THE PROBLEMS

There are many barriers to good communication in the doctor-patient relationship,

including patients' anxiety and fear, doctors' burden of work, fear of litigation, fear of physical or
verbal abuse, and unrealistic patient expectations.31

 Deterioration of Doctors' Communication Skills

It has been observed that communication skills tend to decline as medical students progress
through their medical education, and over time doctors in training tend to lose their focus on
holistic patient care.32 Furthermore, the emotional and physical brutality of medical training,
particularly during internship and residency, suppresses empathy, substitutes techniques and
procedures for talk, and may even result in derision of patients.32

 Nondisclosure of Information

The doctor-patient interaction is a complex process, and serious miscommunication is a

potential pitfall, especially in terms of patients' understanding of their prognosis, purpose of care,
expectations, and involvement in treatment.12 These important factors may affect the choices
patients make regarding their treatment and end-of-life care, which can have a significant
influence on the disease.33 Good communication skills practiced by doctors allowed patients to
perceive themselves as a full participant during discussions relating to their health.10 This
subjective experience that influences patient biology is the †œbiology of self-confidence†•
described by Sobel, which emphasized the critical role of patients' perception in their healing
process.34

 Doctors' Avoidance Behavior

There are reported observations of doctors avoiding discussion of the emotional and social
impact of patients' problems because it distressed them when they could not handle these issues
or they did not have the time to do so adequately. This situation negatively affected doctors
emotionally and tended to increase patients' distress.26 This avoidance behavior may result in
patients being unwilling to disclose problems, which could delay and adversely impact their
recovery.26

 Discouragement of Collaboration

Physicians have been found to discourage patients from voicing their concerns and
expectations as well as requests for more information.32 This negative influence of the doctors'
behavior and the resultant nature of the doctor-patient communication deterred patients from
asserting their need for information and explanations.32 Patients can feel disempowered and may
be unable to achieve their health goals.32 Lack of sufficient explanation results in poor patient
understanding, and a lack of consensus between doctor and patient may lead to therapeutic
failure.32
  Resistance by Patients

Today, patients have recognized that they are not passive recipients and are able to resist the
power and expert authority that society grants doctors.35 They can implicitly and explicitly resist
the monologue of information transfer from doctors by actively reconstructing expert
information to assert their own perspectives, integrate with their knowledge of their own bodies
and experiences, as well as the social realities of their lives.35 Being attentive to social
relationships and contexts will ensure that this information is received, and most importantly,
acted on.35 Lee and Garvin35 asserted that inequality, social relations, and structural constraints
may be the most influential factors in health care. This was illustrated in their study when female
patients from a lower socioeconomic demographic in the Appalachian region of the United
States modified advice to avoid sun exposure and, by taking into account societal pressures that
equated tanned skin with beauty, continued tanning despite knowledge of the risks associated
with sun exposure and skin cancer (Figure). The study by Lee and Garvin35 demonstrates the
need to take into account social factors in the production, dissemination, and use of knowledge.

STRATEGIES FOR IMPROVEMENT

 Communication Skills

Communication skills involve both style and content.36 Attentive listening skills, empathy,
and use of open-ended questions are some examples of skillful communication. Improved
doctor-patient communication tends to increase patient involvement and adherence to
recommended therapy; influence patient satisfaction, adherence, and health care utilization; and
improve quality of care and health outcomes.7,37

Breaking bad news to patients is a complex and challenging communication task in the
practice of medicine.12 Relationship building is especially important in breaking bad news.17
Important factors include understanding patients' perspectives, sharing information, and patients'
knowledge and expectations.12,38 Miscommunication has serious implications, as it may hinder
patients' understanding, expectations of treatment, or involvement in treatment planning.12 In
addition, miscommunication decreases patient satisfaction with medical care, level of
hopefulness, and subsequent psychological adjustment.12

Baile et al12 reported that patients often regard their doctors as one of their most important
sources of psychological support. Empathy is one of the most powerful ways of providing this
support to reduce patients' feelings of isolation and validating their feelings or thoughts as
normal and to be expected.
  Communication Training

Doctors are not born with excellent communication skills, as they have different innate
talents. Instead they can understand the theory of good doctor-patient communication, learn and
practice these skills, and be capable of modifying their communication style if there is sufficient
motivation and incentive for self-awareness, self-monitoring, and training.11,25 Communication
skills training has been found to improve doctor-patient communication.39,40 However, the
improved behaviors may lapse over time.28 It is therefore important to practice new skills, with
regular feedback on the acquired behavior.28 Some have said that medical education should go
beyond skills training to encourage physicians' responsiveness to the patients' unique
experience.10

 Collaborative Communication

Collaborative communication is a reciprocal and dynamic relationship, involving the 2-way

exchange of information.41 In an ideal world, doctors should collaborate with their patients to
provide the best care because doctors tend to make decisions based on quick assessments, which
may be biased.41 This requires the doctors to take time or set up opportunities to offer and
discuss treatment choices to patients and share the responsibility and control with them.7,11
Successful information exchange ensures that concerns are elicited and explored and that
explanations of treatment options are balanced and understood to allow for shared decision
making.7,11,14,42 In this approach, the doctor facilitates discussion and negotiation with
patients and the treatment options are evaluated and tailored to the context of the patients'
situation and needs, rather than a standardized protocol.7,11,42 Care options need to be
collaborative between doctor and patient, taking into account patient expectations, outcome
preferences, level of risk acceptance, and any associated cost to maximize adherence and to
assure the best outcome.32

 Conflict Management

Feudtner41 described situations in pediatric palliative care in which the cause of conflicts
was often not expressed. The root source was often unspoken and thus unclear or unknown to
one or even both parties, which generated feelings of discord. Conflict is often a challenging
situation as it can evoke feelings of helplessness, frustration, confusion, anger, uncertainty,
failure, or sadness.11 The doctor should recognize these feelings and develop skills to identify
problematic responses in the patient or themselves to de-escalate the situation and enable the
relationship problems to be turned into a clinical success.11

In addition to minimizing avoidance behavior, which prevents patients from expressing

opinions, effective doctor-patient communication should involve productive conversation, which
involves understanding of both parties' perspectives, by shifting from a perspective that is rigidly
certain of one's belief to a more exploratory approach that strives to understand the situation
from another perspective.41 Recognizing the impact of patient reciprocation of communication
and affect in a medical visit is important as it may help create positive exchanges to defuse
negative patterns.25

 Health Beliefs

Beliefs and values affect the doctor-patient relationship and interaction.9 Divergent beliefs
can affect health care through competing therapies, fear of the health care system, or distrust of
prescribed therapies.37 This perception gap may negatively affect treatment decisions and
therefore may influence patient outcomes despite appropriate therapy.17 Although doctors use a
biomedical model to understand illness, patient beliefs and values are influenced by social and
behavioral factors as well as biology or anatomy.17

It is important to identify and address perceived barriers and benefits of treatment to improve
patient adherence to medical plans by ensuring that the benefits and importance of treatment are
understood.17 Doctors should understand patients' functional meaning of disease, as well as the
relationship meaning and symbolic meaning, followed by a summary of this information and
telling the patient the problem from the doctor's perspective and, finally, asking the patient to
summarize what was said.17 Agreement between doctor and patient is a key variable that
influences outcome.17

Patients construct their own version of adherence according to their personal world views
and social contexts, which can result in a divergent expectation of adherence practice.9,13,15
Good doctor-patient communication is a mechanism used to gain an understanding of patients'
social context, expectations, and experience.9,13,42 With collaborative communication, a
particular condition, perspective, or fact can be identified, allowing for a view from a different
perspective, drawing attention for a better assessment and the subsequent treatment.41 In this
model, effective doctors acknowledge and respect patients' rights to make decisions and
choices.13

LIMITATIONS AND FUTURE DIRECTIONS

Clinical research will guide improvements in determining best practice. Randomized

controlled trials are able to effectively control bias and chance in evaluating efficacy. However,
this is easier said than done in terms of investigations of communication. A majority of the
studies reported in this review were cross-sectional.7 However, doctor-patient relationships are
frequently long term, involving multiple visits, and this may limit the generalizability of the
studies.

The approaches used in assessing doctor-patient communication and health outcomes in

the literature are shown in the Table.7,30 Behavioral and observational components involve
recordings to evaluate the actual medical encounter and analyze it in order to code behavior
based on one of the observational instruments with respect to task and socioemotional
behaviors.7,14,30 The patients' perception measures are assessed via surveys to rate frequency,
occurrence, or other elements of physician behavior.7,14,43 Patients' perceptions may have a
greater impact on their own outcomes than physician behavior, but their perceptions are
subjective and subject to bias, and patients may be influenced by other factors such as their
health status and state of mind and may not accurately reflect the reality of the consultation.7

Approaches in Assessment of Doctor-Patient Communication

Comparisons between studies are difficult as numerous tools are available but no single
tool is completely satisfactory. Different studies use combinations of different tools for this
reason. In addition, items are generated for measurement of patient perceptions without
predefined categories of doctors' behaviors.7

Qualitative measures, although difficult to gauge, can provide a deeper understanding of

patients' subjective perceptions. Clinically the most easily quantified outcomes are physiological
measures, but these may not be possible in many surgical or chronic illnesses.19 They are also
highly specific and may contribute minimally to an understanding of the patient's overall
health.19 Satisfaction is a complex notion with many determinants and is used as the ultimate
outcome of the delivery of health care services as it is a proxy for health, and its rating provides
useful information about the structure, process, and outcomes of care.21,44 Morss et al, as
quoted by Alazri and Neal,21 reviewed 21 relevant qualitative studies and found that the
domains used to assess patient satisfaction with care included availability of the physician,
coordination in a multidisciplinary team, competence, communication and relationships, ability
to provide information and educate patients, responsiveness to emotional needs of patients,
ability to provide holistic care, and ability to support patients' decision making. Satisfaction
contributes to better medical outcomes through fulfillment of patients' values and
expectations.21 Patients who experience good processes and outcomes of care are more satisfied
and therefore more likely to continue maintaining the existing doctor-patient relationship.21

The main independent predictors of satisfaction have been patients' perceptions of

communication and partnership, and a positive doctor approach.27 Satisfaction strongly predicts
compliance with treatment and medical outcomes in acute illness.27 However, its use in medical
interviews to relate to patient-centeredness may be inaccurate as its scales include subscales on
communication.27

A majority of the literature frequently uses patient satisfaction and adherence to

determine the efficacy of the doctor-patient relationship.7,39 The ability to generalize is limited,
depending on, among other things, the size and representative nature of the specific population
studied.7,36 Satisfaction needs to be investigated with a tightly defined and homogenous case
mix to explore cause and effect of various factors on doctor-patient communication.27 In
addition, the Hawthorne effect (awareness that one is being observed and evaluated) is difficult
to avoid in observational studies and may affect behavior.5,45

CONCLUSION

The patient will never care how much you know, until they know how much you care.
(Terry Canale in his American Academy of Orthopaedic Surgeons Vice Presidential Address9)

Doctor-patient communication is a major component of the process of health care.46

Doctors are in a unique position of respect and power. Hippocrates suggested that doctors may
influence patients' health.19 Effective doctor-patient communication can be a source of
motivation, incentive, reassurance, and support.19,47 A good doctor-patient relationship can
increase job satisfaction and reinforce patients' self-confidence, motivation, and positive view of
their health status, which may influence their health outcomes.19,47

Most complaints about doctors are related to issues of communication, not clinical
competency.9,29,42 Patients want doctors who can skillfully diagnose and treat their sicknesses
as well as communicate with them effectively.32

Doctors with better communication and interpersonal skills are able to detect problems
earlier, can prevent medical crises and expensive intervention, and provide better support to their
patients. This may lead to higher-quality outcomes and better satisfaction, lower costs of care,
greater patient understanding of health issues, and better adherence to the treatment
process.29,32 There is currently a greater expectation of collaborative decision making, with
physicians and patients participating as partners to achieve the agreed upon goals and the
attainment of quality of life.32