April 23, 2019

Communicating with patients. What is the best strategy?

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By Jacquie Rainey, DrPH, MCHES
College of Health and Behavioral Sciences,
University of Central Arkansas

 

Effective communication with patients is integral to a patient and family-centered approach to care. Effective communication contains elements such as establishing rapport, gaining trust, determining readiness to learn (change), considering the patient’s perspective and asking the right questions. The question is: How we do this in the limited amount of time we have to see a patient? Techniques talked about often involve paying attention to the patient’s concerns, asking them about their motivations, talking about their fears, and listening carefully to their concerns and core beliefs. Two approaches to communication that have gained popularity are motivational interviewing (MI),1 and  health literacy.


Motivational Interviewing

Motivational interviewing is a communication method that can aid in the development of the patient-provider relationship and thus enhance adherence to medical regimens and behavior change, as well as increase patient satisfaction. Motivational interviewing has been defined as “.. a collaborative, person-centered form of guiding to elicit and strengthen motivation for change.” 2

MI has been described as a complex set of client-centered skills of reflective listening and not a technique that can be learned from a few hours of training. It involves the use of specific communication strategies that are designed to get to the heart of a person’s motivation to change. Miller and Rollnick believe that some clinicians may intuitively practice elements of MI. The use of ‘guiding’ someone to a decision when they are dealing with a problem is a mix of asking, listening and providing information. This type of communication is a common practice among many clinicians. However, MI is true reflective listening in the face of ambivalence from the patient or even irrational and contradictory motives. The purpose of MI is to help the patient recognize their own thoughts and goals and facilitate change. It is a true collaboration between the patient and the provider. The provider uses interviewing to draw out the patient’s ideas and motivations rather than telling them what they should do, and thus empowering the individual to take responsibility for their actions. MI has shown to be effective with older adults in influencing change related to weight loss, medication management and exercise.3 Although MI has a lot to offer in effective patient communication, most healthcare providers are not effectively trained in this technique and do not have enough time with the patient to appropriately employ this method.


Health Literacy

Other suggestions for effectively communicating with patients come from the field of Health Literacy. Health Literacy involves communicating with a patient in a manner that ensures the patient understands and is able to utilize the information provided to make an informed decision. Teach back is one technique that requires the healthcare provider to listen to the patient explain their understanding of the desired action or information. If the patient can’t explain the desired action then the provider attempts to convey the message in another way. The Ask Me 3 approach from Health Literacy requires the patient to ask the healthcare provider three questions: What is my main problem? What do I need to do? Why is it important for me to do this? These are all very important questions but they are clinician-centered rather than patient-centered. The questions may lead to more knowledge and understanding but they do not encourage shared decision making and goal setting and thus patient empowerment. 4


Effective Listening

Effective listening is often described as a lost art in medicine. In one study, family practice and internal medicine residents spent an average of 12 seconds letting the patient speak before interrupting them during primary care visits, often interrupting before the patient had finished explaining an issue.5

To be an effective advocate for the patient and partner in their healthcare the provider needs to find out who the patient really is, where they are in their healthcare, and how they want to proceed. Ronald Epstein M.D. discusses healthcare providers being present in the moment when communicating with patients in his book Attending: Medicine, Mindfulness and Humanity. He describes being present as listening deeply, without interruption, judgement or preconceptions..6 The provider needs to learn whether the patient understands the diagnosis and also the patient’s perspective of her health status and options.

Suneel Dhand believes the one question doctors utilize the least is asking the patient, “What are your goals?” This question gets at what the patient would like to see as an outcome of the encounter. It is particularly important to ask this of older adults who may be dealing with multiple health challenges. It elicits the patient’s expectations for their care and shows that the provider cares about them and their health. It engages the patient in their own healthcare and fosters the patient-provider relationship.7

The core element of MI, health literacy and effective patient education/communication is listening. By exploring the patient’s goals and values and determining what they want from their care, the provider can determine if the desired behavior or treatment fits in with the person’s values. Does the behavior change or healthcare plan help to accomplish an important goal or does it interfere with the goal?

Questions that could be used to help elicit goals are:

What specifically would you like to work on to manage your condition?

How important do you think it is to manage/treat your condition?

What is the most important thing for you to accomplish with your care?

Then just listen………

Markides states, “We don’t have to talk all of the time. When someone tell us her problem we healthcare professionals tend to want to give her a solution or say something to cheer her up because we feel uncomfortable watching her suffering. That’s not always the right thing to do. There are times that we need to learn to say nothing and just listen to the other person.”8

 

 

  1. Martin, L. Communicating with patients. Medline Plus, US. National Library of Medicine. https://medlineplus.gov/ency/patientinstructions/000456.htm review date 11/20/17. Accessed March 1, 2019.
  2. Miller WR, Rollnick S. Ten things that motivational interviewing is not. Behavioural and Cognitive Psychotherapy, 2009; 37, 129-140.
  3. Beagley D, Bonifas R. Motivational interviewing with older adults. Eder care: a resource for interprofessional providers. University of Arizona College of Medicine Tucson; 2016.
  4. Beyond AskMe3. http://www.ihi.org/education/Documents/ProgramMaterials/CDCMillionHeartsBloodPressureProject/BeyondAskMe3.pdf. Accessed March 1, 2019.
  5. Rhoades DR, McFarland KF, Finch WH, Johnson AO. Speaking and interruptions during primary care office visits. Family Medicine.2001;33(7,) 528-32.
  6. Mindful Practice. http://www.ronaldepstein.com/mindful-practice. Accessed March 1, 2019.
  7. The simple powerful question doctors should ask their patients. https://www.kevinmd.com/blog/2018/07/the-simple-powerful-question-doctors-should-ask-their-patients.html. Accessed March 1, 2019.
  8. Markides M. The importance of good communication between patient and health professionals. Journal of Pediatric Hematology Oncology. 2011;33, S123-S125.