Challenges in communication for a good doctor-patient relationship

Communication is one of the most important factors in the doctor-patient relationship. Patients’ quality of life, decision-making and adherence often depend on the doctor’s communication skills. In addition, a close doctor-patient relationship is the best protection against suicide. What can successful communication look like – especially in emotionally stressful situations?

It is not always easy to strike the right note as a practitioner, especially in a situation that is emotionally charged for the patient. It’s not necessarily about the words chosen or the sound of the voice. The different points of view with regard to therapy, for example, can turn the doctor-patient discussion into a balancing act. While the focus of the consultation from a doctor’s perspective is on the best possible treatment, patient motivation and adherence, the patient prefers topics such as safety, quality of life and hope. It’s not so easy to reconcile all your needs. Especially in view of the scarce resource of time. Communication skills are therefore essential in order to strengthen the relationship with patients and their relatives, promote the quality of life of those affected and support decision-making with regard to treatment.

The importance of communication and one’s own attitude towards the patient should not be underestimated. If the uncertainty and fears become too great, a conversation can provide security and support. It is therefore essential to meet the person concerned where they are. What is his current understanding of the disease? What hopes, wishes and life circumstances does he bring with him? However, it is also important to find out who wants the therapy, for example. Is it the affected person themselves, or rather their relatives? Is there a sufficient “for what”? The question of the need for safety should also be addressed in order to ultimately be able to initiate suitable therapy management. In the further course, good monitoring of quality of life is then indicated in order to be able to react promptly to possible restrictions. If problems occur, if the patient feels insecure or struggles with their fate, they should be taken seriously. Therefore, it could be worthwhile to engage in mindful communication. Studies have found that a sustained, high-quality connection between patients and their oncologist provides better protection against suicidal thoughts than any other mental health intervention, including psychotropic medications [1]. On the other hand, the likelihood of a patient contemplating suicide or dying by suicide increases if they feel abandoned and without care [2]. Patient satisfaction and adherence therefore depend crucially on the doctor-patient discussion. Communication skills are usually the key to success here. A few simple tricks can optimize the conversation.

Do you understand me?

Everyone hears only what he understands. As nonsensical as this sentence may seem at first glance, there is a lot of truth in it. If the patient cannot follow the doctor’s explanations, the risk that the therapy will not be implemented as desired is very high. Noncompliance is a widespread problem. Half of the medications are actually not taken properly – predominantly because patients have reservations about the therapy. But these are rarely addressed to the physician. Also, responsibility is often shifted to the physician. So what needs to be done to make treatment more successful? One study found that the doctor’s communication skills correlate with patient satisfaction by a factor of 0.71 [3]. A key element here is attention and appreciation, as this leads directly to an increase in patient self-esteem. In addition, the patient should participate in the decision-making process regarding therapy management in a well-informed manner.

A good feeling right from the start

The patient should therefore be the focus of interest and communication. Make decisions in a participatory and mutually agreed process [4]. However, the cornerstone of a positive conversation is already laid when the first contact is made. Therefore, experts recommend to pick up the patient from the waiting room yourself. Eye contact and listening have emerged as other important parameters. For many patients, it is important to be able to get everything off their chest in the first minute. An open start to the conversation, such as “Please tell….” opens up the conversation space in which the patient can express his or her needs without being directed in a particular direction. On average, doctors interrupt their patients after 11 to 24 seconds [5]. This can cause important information to be lost. This is because sufferers often do not start their conversation with the most distressing symptom, but save this until the end [6]. And experience shows that patients who are not interrupted usually finish their remarks after 60 to 90 seconds anyway.

Creating a secure basis

It is also important to realize that communication is not about being able to solve all problems immediately. Rather, the goal is to establish a secure and competent basis for therapy. At the same time, one should not underestimate the fact that degeneration of content occurs. There can be big differences between what the doctor means, what he says and what the patient understands. Paraphrasing and summarizing can ensure that the doctor and patient mean the same thing. In addition, pauses are important to give the affected person the opportunity to process what he or she has heard. Completion questions allow the assignment of complaints to a clinical picture. Here, too, the golden rule is to ask open rather than closed questions. The latter should be used deliberately only at the end of the case history, when the focus narrows. Then a change is made from a patient-centered to a doctor-centered conversation, which clarifies the basic participatory element of the relationship. This is because participatory decision-making is defined as an “interaction process with the aim of reaching a jointly responsible agreement on the basis of shared information with the equal and active participation of patient and doctor” [7].

Reduced receptivity in stressful situations

On average, people can remember seven new pieces of information. In an emotionally stressful situation, however, the absorption capacity is reduced to a minimum. This could result in the fact that 93% of all those affected want information, but only 18% feel well informed [8]. Therefore, the information relevant to the patient should be summarized again at the end of the interview. In addition, you should always ask what is remembered from this conversation. Negative exaggerations on the part of the patient should be toned down and positive development opportunities should be pointed out. This is known as the framing effect. The same facts are given a different meaning simply by rephrasing them. To give a simple example: it makes a difference to our perception whether a yogurt consists of 5% fat or 95% fat-free. Or the view of whether a glass is half full or half empty. The conversation should therefore take the fears seriously, but also point out the development possibilities. So you don’t have to be afraid. There have practically never been any side effects. I see no reason why you should be worried. Don’t think so much about it….” could be better formulated by saying, for example: “Your excitement is understandable. Many of my patients feel that way at first. But you will see that it is a well-tolerated preparation. I often give it very successfully. You will feel much better and you will be able to enjoy the things that give you pleasure more again…”. A good key question at the end of a conversation can also be to consider what knowledge deficit could harm the patient until the next contact.

Clear structure creates security

It has proven successful to follow a clear structure with the description of the situation, the setting of priorities, the processing of the illness, the view of the resources up to the clarification of the treatment order in order to support the patient in the best possible way. In any doctor-patient communication, the problem of “silence post loss” can occur: There can be a big difference between what the doctor means and what he says, and one should be aware of this. What the patient hears and what he actually understands can differ significantly from the initial message (Fig. 1) . It is therefore not only sensible but also necessary to limit yourself to a small amount of relevant information and to be as clear as possible when conveying the message.

When the world is upside down

What you should always keep in mind: it’s one sentence – and the patient’s world is turned upside down. A potentially life-threatening or life-impairing diagnosis catches most people off guard and leaves them feeling uncertain and anxious. For the patient, the entire life changes with the disease. Therefore, a careful approach adapted to the person concerned is essential (Table 1). In this vulnerable phase, a strengthened doctor-patient relationship is all the more important. Diagnosis is often followed by an immediate onset of dependence on medical providers, not infrequently coupled with frenzied actionism. Now it is important to also pay attention to the quiet tones and to read between the lines. In particular, topics such as fear of pain, the family situation and the burden on relatives, previous experiences with the disease or later fear of recurrence are topics that need to be discussed but are not always addressed by the person affected.

Also pay attention to your own needs

Being the bearer of bad news is also stressful for the physician. On the one hand, you should assess the situation professionally and act accordingly. On the other hand, you are also a person with feelings and empathy, which should also be addressed. The patient is in crisis. This is defined as “an acute overload of a habitual behavioral and coping system” [9]. What follows is a state of shock, which, in addition to an intense feeling of threat, also causes a mental imbalance. Nevertheless, there is pressure to act. Not an easy situation. Flushing, sweating, palpitations, pallor and nausea may now occur as well as overexcitement, increased irritability and severe mood swings. If the patient takes his feelings out on you, it is essential to realize that this has nothing to do with you as the bearer of the news. It is not for nothing that the bearers of bad news were executed in the past. Someone who shows understanding usually gets through to the patient better than someone who shrugs off the reaction.

Even more difficult to endure than aggressive behavior, however, is speechless horror or crying. Even if the feeling of wanting to help is understandable – it is not possible. Platitudes are out of place now. You can often show your sympathy simply by handing the person a tissue. Also, offer that you are available to talk at any time if needed. Generally, such an acute stress situation lasts for several hours to a maximum of three days. If the symptoms persist for a longer period of time, the patient does not have sufficient resources to cope with the situation. The feeling of helplessness and loss of control take over. Here, coping strategies must be offered so that the crisis can be overcome.

Interview guide provides assistance

One of the most popular discussion guidelines developed specifically for oncology is the SPIKES protocol (Table 2) [10]. It aims to enable the physician to fulfill the four main goals of the bad news disclosure interview: Gathering information from the patient, communicating the medical information, supporting the patient, and eliciting the patient’s cooperation in developing a strategy or treatment plan for the future. Even with the worst news, good communication has a positive impact on receptivity, patient satisfaction, adherence, and thus a successful therapy. Friendliness, interest and moderate medical dominance proved to be particularly positive [11].

The difficult patient

The patient does not always react as the doctor expects. Then the entire operations can falter because more time, energy and attention are needed. Scientists have verified different types of patients who have developed individual strategies to be perceived as an individual and to experience emotional support (Tab. 3) . Basically, the lower the self-esteem, the greater the vulnerability. Therefore, especially in this case, a prudent and skillful reaction of the physician is essential.

Learning to understand non-verbal language

More than 90% of our communicative impact does not come from our words. Rather, it is created through body language, gestures, facial expressions, speech tempo and pitch [12]. Through practice, you can manage to appear outwardly open, calm, and approachable, while inwardly seething. However, the nonverbal signals only become convincing if we actually think in an appreciative way. A state of receptive curiosity can be helpful here. Instead of getting angry about a reaction, you can ask yourself how and on what basis it might have come about. By taking an observational stance, you don’t feel personally attacked as quickly. Ultimately, behavior depends less on the objective situation than on its interpretation. Based on one’s own experiences, hypotheses are created about how a situation will go. Therefore, two people in the same situation can also react differently.

Take-Home Messages

• Communication is one of the most important factors in the doctor-patient relationship.
  Ratio.
• Quality of life, decision-making and adherence often depend on
  the doctor’s communication skills.
• A close doctor-patient relationship is the best protection against suicide.
• As a rule, communication skills play a greater role than the doctor’s clinical experience.
• Attention and appreciation create trust.
• Pauses in the conversation allow the patient to catch up mentally.
• Emotional situations impair absorption capacity.

Literature:

1. Trevino KM, Abbot CH, Fish MJ et al. Patient-Oncologist Alliance as Protection against Suicidal Ideation in Young Adults with Advanced Cancer. Cancer 2014; 120: 2272-2281.
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3. Langewitz W, Denz M, Keller A, et al: Spontaneous talking time at start of consultation in outpatient clinic: cohort study. BMJ 2002; 325(7366): 682-683.
4. Stewart MA, Brown JB, Weston WW, et al: Patient-centered medicine: Transforming the clinical method. Second edition. Int J Integr Care 2005; 5: e20.
5. Wilm S, Knauf A, Peters T, Bahrs O: When do primary care physicians interrupt their patients at the beginning of the consultation? Z Allg Med 2004; 80: 53-57.
6. Burack RC, Carpenter RR: The predictive value of the presenting complaint. The Journal of Family Practice 1983; 16(4): 749-754.
7. Bieber C, Gschwendtner K, Müller N, Eich W. Participatory decision making (PEF) – patient and physician as a team. Psychother Psych Med 2016; 66: 195-207.
8. Ochsner KN, Gross JJ, et al: Cognitive Emotion Regulation: Insights from Social Cognitive and Affective Neuroscience. Curr Dir Psychol Sci 2008; 17(2): 153-158.
9. Simmich T, Reimer C: Psychotherapeutic aspects of crisis intervention. A literature review with special reference to the last 10 years. Psychotherapist 1998, 43: 143-156.
10. Baile WF, Buckman, Lenzi R, et al: SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist 2000; 5: 302-311.
11. Swedlund MP, et al: Effect of Communication Style and Physician-Family Relationships on Satisfaction With Pediatric Chronic Disease Care. Health Commun. 2012; 27: 498-505.
12. Ehlich K, Rehbein J: Pattern and institution: studies in school communication. 1986.

InFo ONCOLOGY & HEMATOLOGY 2023; 11(5): 12-16