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JOURNAL ARTICLE
REVIEW

Patient-doctor communication

Carol Teutsch
Medical Clinics of North America 2003, 87 (5): 1115-45
14621334
Communication is an important component of patient care. Traditionally, communication in medical school curricula was incorporated informally as part of rounds and faculty feedback, but without a specific or intense focus on skills of communicating per se. The reliability and consistency of this teaching method left gaps, which are currently getting increased attention from medical schools and accreditation organizations. There is also increased interest in researching patient-doctor communication and recognizing the need to teach and measure this specific clinical skill. In 1999, the Accreditation of Council for Graduate Medical Education implemented a requirement for accreditation for residency programs that focuses on "interpersonal and communications skills that result in effective information exchange and teaming with patients, their families, and other health professionals." The National Board of Medical Examiners, Federation of State Medical Boards. and the Educational Commission for Foreign Medical Graduates have proposed an examination between the. third and fourth year of medical school that "requires students to demonstrate they can gather information from patients, perform a physical examination, and communicate their findings to patients and colleagues" using standardized patients. One's efficiency and effectiveness in communication can be improved through training, but it is unlikely that any future advances will negate the need and value of compassionate and empathetic two-way communication between clinician and patient. The published literature also expresses belief in the essential role of communication. "It has long been recognized that difficulties in the effective delivery of health care can arise from problems in communication between patient and provider rather than from any failing in the technical aspects of medical care. Improvements in provider-patient communication can have beneficial effects on health outcomes". A systematic review of randomized clinical trials and analytic studies of physician-patient communication confirmed a positive influence of quality communication on health outcomes. Continuing research in this arena is important. For a successful and humanistic encounter at an office visit, one needs to be sure that the patient's key concerns have been directly and specifically solicited and addressed. To be effective, the clinician must gain an understanding of the patient's perspective on his or her illness. Patient concerns can be wide ranging, including fear of death, mutilation, disability; ominous attribution to pain symptoms; distrust of the medical profession; concern about loss of wholeness, role, status, or independence; denial of reality of medical problems; grief; fear of leaving home; and other uniquely personal issues. Patient values, cultures, and preferences need to be explored. Gender is another element that needs to be taken into consideration. Ensuring key issues are verbalized openly is fundamental to effective patient-doctor communication. The clinician should be careful not to be judgmental or scolding because this may rapidly close down communication. Sometimes the patient gains therapeutic benefit just from venting concerns in a safe environment with a caring clinician. Appropriate reassurance or pragmatic suggestions to help with problem solving and setting up a structured plan of action may be an important part of the patient care that is required. Counseling around unhealthy or risky behaviors is an important communication skill that should be part of health care visits. Understanding the psychology of behavioral change and establishing a systematic framework for such interventions, which includes the five As of patient counseling (assess, advise, agree, assist, and arrange) are steps toward ensuring effective patient-doctor communication. Historically in medicine, there was a paternalistic approach to deciding what should be done for a patient: the physician knew best and the patient accepted the recommendation without question. This era is ending, being replaced with consumerism and the movement toward shared decision-making. Patients are advising each other to "educate yourself and ask questions". Patient satisfaction with their care, rests heavily on how successfully this transition is accomplished. Ready access to quality information and thoughtful patient-doctor discussions is at the fulcrum of this revolution.

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