Clinician-Patient Communication: Its Big Impact on Health

CPC Corner
Clinician-Patient Communication:
Its Big Impact on Health
By Vivian Tong Nagy, PhD

With all our other concerns, we can easily lose our focus on improving health. Indeed, good clinician-patient communication is often emphasized not because it is related to health outcomes but because communication skills are related to higher patient satisfaction scores, less malpractice litigation, lower rates of voluntary termination from Health Plan membership, and increased clinician satisfaction.² Although we often conduct our efforts to improve communication between clinicians and patients in the context of these outcomes--and rightly so--we must not lose sight of the important link between effective communication and patient health behavior.

This article summarizes the published evidence linking communication and health outcomes and discusses how components of good communication affect patients' perception of the medical encounter as well as their subsequent health behavior.

Communication and Health Outcomes

The need for more research on clinician-patient communication

A recent editorial in the Annals of Internal Medicine emphasized that clinicians want information that regularly helps them take better care of their patients. The editorial called for more research aimed at improving communication between doctors and patients.⁹

This focus on research in clinician-patient communication is echoed here at KP. This year, the Garfield Memorial Fund released a Request for Applications for research addressing clinician-patient communication and will award grants to projects that hold promise for improving clinician-patient communication throughout the KP Program.

Research clearly shows that effective clinician-patient communication is correlated with desired health outcomes. Major review studies^3-5 have systematically examined the body of evidence accumulated over the past several decades. In most of these studies, interventions were designed to improve clinician-patient communication and thus improve health outcomes such as symptom resolution (eg, control of headaches), functioning (eg, asthma functioning), physiologic measures (eg, blood pressure, blood sugar level), pain control (eg, cancer pain, dental pain), or emotional status (eg, mood, anxiety). More than half the studies showed a link between effective clinician-patient communication and improved health outcomes.^3-5

In addition, other studies^6-8 documented that poor communication between a clinician and a patient during a clinical encounter fails to elicit important health-related information from the patient and causes both clinician and patient to misunderstand the health situation. As a result of incomplete or inaccurate information, opportunities for improving health are missed (see Sidebar below).

What do clinicians with good communication skills do that influences health behavior and improves health outcomes? According to research findings,^3,6,11-13 skilled clinicians 1) elicit the patient's point of view, 2) involve the patient in decisions related to treatment and management, and 3) develop the clinician-patient relationship.

	Results of poor communication in the clinical interview^3,6,10
	Clinician does not elicit patient's complaints and concerns Clinician misses patient's psychosocial and psychiatric problems Patient does not clearly communicate main presenting problem to clinician Patient does not understand or remember information about the diagnosis and treatment Cultural issues are not addresses

Elicit the Patient's Point of View

In an effective interview, the clinician gathers not only objective information about a patient's health condition but also understanding of the patient's own perspective regarding her or his health. In any situation, the appropriate course of treatment may be clear from the medical perspective of the clinician; nonetheless, for the patient, other considerations are also important. Patients weigh the perceived advantages of prescribed therapy against such factors as potential risks or side effects and anticipated limitations on daily habits or preferences.^11,14-17

During the interview, the clinician has an opportunity to discover a patient's perspective by asking questions: What type of person is the patient? How does the patient experience the illness or health condition in question? What is the patient's understanding of the health situation? (See Practice Tips box.) A patient-centered interview such as this uncovers information that leads the clinician and patient to discuss treatment alternatives and choose the approach most acceptable to the patient.^6,12 In contrast, failure to identify and effectively address a patient's understanding and feelings about his or her health situation is likely to lead to a poor outcome.^3,6

How communication affects health outcomes³

Clinician gathers information from patient
Clinician and patient discuss care management plan
Clinician provides emotional support
Clinician and patient share in making treatment-related decisions

Involve the Patient in Care Management Decisions

Considerable evidence shows that a patient who is involved in determining the treatment approach is most likely to comply with treatment.^3,7,13,18,19 Participation of the patient helps clinicians to determine how various treatment options fit the patient's goals and preferences and enables the patient and clinician to reach a mutually agreeable decision.¹⁸ A patient who is involved in treatment discussions or who engages in shared decision making has a greater sense of personal control as well as lower levels of concern about her or his condition and a better outcome,^13,19 whereas a patient who does not participate in the consultation is more likely to be noncompliant with treatment.^3,7

Develop the Clinician-Patient Relationship

Perhaps the strongest relationships between a patient and a clinician are established over time. In primary care, continuity of the clinical relationship is important; indeed, the definition of primary care set forth by the Institute of Medicine (IOM), in 1996, includes "a sustained partnership with patients."^20:1 The continuity fostered by primary care provides opportunities for the clinician and patient to become familiar with each other, develop effective communication patterns, and establish mutual trust.

Developing the clinician-patient relationship establishes fertile conditions for primary care clinicians to provide health behavior education and health screening. Indeed, interpersonal communication between a provider and a patient--and the clinician's knowledge of the patient--have been measured in primary care settings and have been associated with desired health behaviors such as up-to-date delivery of screening services, delivery of messages about preventive health behavior, up-to-date immunizations, and modification of high-risk health behavior.^8,21

Programs for Improving Clinical Communication
at Kaiser Permanente

How can we improve our KP clinicians' ability to elicit a patient's point of view, involve a patient in making decisions related to treatment and care management, and develop the clinician-patient relationship? The KP Interregional Clinician-Patient Communication (IRCPC) Leadership Group has developed a variety of educational workshops and programs that are available in all KP regions to address these critical components of communication.^2,22 (See Practice Tips box.) For more information about these programs, contact Geoff Galbraith, MD, (Geoff.Galbraith@kp.org) or Elizabeth Wu (Elizabeth.X.Wu@kp.org) (cochairs of the IRCPC Leadership Group).

Practice Tips
Discover the person: "Can you tell me a little bit about yourself--your home, your work, what's important to you?
Elicit experience: "I imagine this illness is very hard for you. What has it been like?"
Elicit understanding: "What do you think is causing your condition? Why right now?"
Elicit concerns: "Some people have concerns about this--what are your concerns about this?" "How do you feel about this?"
Elicit feedback: "Does this make sense to you, or is it still somewhat unclear?"
Elicit preferences (especially where there are real options for patients): "What option would you prefer?"
Elicit expectations: (Especially about treatment): "How much improvement do you expect from this?"

Summary

The clinician-patient communication process in any medical encounter affects health behavior and health outcomes.

Acknowledgments
Alison Truman, MS, and Elizabeth L Johnston, MA, assisted with the literature search.

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