Improving doctor-patient communication

Not an option, but a necessity

In most Western countries healthcare systems are changing; political and economic forces are behind the growth of profit driven medicine, managed care, and an increasingly technological focus. Paradoxically, at a time of global communication and the “Net generation,” we are faced with a breakdown in communication between patients and doctors, increasing patient dissatisfaction, rising numbers of complaints and claims for malpractice, and abandonment of conventional medicine for alternatives that are often unproved.1

What do patients want? Most complaints by patients and the public about doctors deal with problems of communication not with clinical competency.2 The commonest complaint is that doctors do not listen to them. Patients want more and better information about their problem and the outcome, more openness about the side effects of treatment, relief of pain and emotional distress, and advice on what they can do for themselves. Several studies have clearly shown that doctors and patients have different views on what makes good and effective communication.3-5 These differences influence the quality of interactions between doctors and patients, as well as compliance, patient education, and health outcomes.

Why should doctors change the way they communicate? In the past decade responsibility for an individual's health care has shifted. Patients today are health consumers and want to be active participants in medical decision making. Kaplan et al showed that patients tended to leave doctors who failed to involve them in decisions.6 In this observational study of 7730 patients and their doctors, a third of those rating doctors in the lowest participatory quartile changed doctors the following year. Furthermore, doctors who had training in interviewing skills scored higher than those without such training. Under pressure to contain costs, doctors respond by increasing their practice volume, with a corresponding decrease in time spent per patient.7 This is a false economy if, as Kaplan suggests, it results in patients abandoning that doctor.

Good doctor-patient communication offers patients tangible benefits. Many studies have found significant positive associations between doctors' communication skills and patients' satisfaction.8 Does good communication improve physical health too? Several studies and reviews clearly show a correlation between effective communication and improved health outcomes.9 The outcomes affected were emotional health, resolution of symptoms, function, pain control, and physiological measures such as blood pressure and blood sugar concentration.

How can we overcome the difficulties doctors have in learning new communication skills? Firstly, there is plenty of good evidence that changing doctors' behaviour and communication skills can be achieved quite easily with proper teaching and that it will last. 8 10 11 Secondly, despite the changes in the structure and practice of medicine, it is still more than just a job. Doctors have a moral and social responsibility as well as a medical one and must preserve their patients' trust. Thirdly, communication is an interactive process. Patients will also need skills and support to take part in decision making and raise questions about quality. Efforts to improve quality increasingly incorporate patients' perspectives, and providers who know what services patients value can work to meet expectations or counsel patients so that expectations become more realistic. There is encouraging evidence that some of the issues addressed in the Toronto consensus statement on doctor-patient communication have already begun to change awareness.12 The Toronto consensus statement published in 1991 clearly showed that communication problems in clinical practice are important and common. It also showed that quality of communication is related to health outcomes for patients, but that traditional medical education is ineffective at teaching communication. New teaching methods and media have been developed since then, but current knowledge has yet to achieve broad implementation in practice.

Learning communication skills in times of change and uncertainty depends on an emotional openness to self and others. Medical educators should use knowledge of patients' perceptions of care to focus teaching on areas that will help trainees to meet patients' expectations.4 Teaching communication skills should be included at all levels of medical education and, even more importantly, should be a mandatory element of the medical school curriculum and programmes of continuing medical education. This can be achieved only with the support of all grades of doctors in all specialties.