As a result of electronic access to medical information, patients sometimes have more specific medical knowledge of a given medical problem than the physician does. When this is the case, the physician must avoid feeling defensive. The patient often lacks broader knowledge of the context of the problem, awareness of the variable reliability of electronic sources of information, the ability to assess a given study or journal report within an historical context or in comparison with other studies on the topic, knowledge of drug interactions, an ability to maintain objective intellectual distance from the topic, or essential experience in the art and science of medicine. The physician possesses these skills and extensive knowledge, whereas the patient has an intensely focused personal interest in her specific medical condition. Surveys of physicians’ perceptions of the impact of Internet-based health information on the doctor–patient relationship found both positive and negative perceptions; physicians express concerns about a hindrance to efficient time management during an office visit, but a positive perception of the potential effects on the quality of care and patient outcomes (19). A collaborative relationship that allows patients greater interactive involvement in the doctor–patient relationship can lead to better health outcomes (1,20,21).
The pattern of the physician’s speech can inﬂuence interactions with the patient. Some important components of effective communication between patients and physicians are presented in Table 1.2. There is evidence that scientifically derived and empirically validated interview skills can be taught and learned, and conscientious use of these skills can result in improved outcomes (8). A list of such skills is found in Table 1.3.
For physician–patient communication to be effective, the patient must feel that she is able to discuss her problems in depth and in confidence. Time constraints imposed by the pressures of office scheduling to meet economic realities make this difficult; both the physician and the patient frequently need to reevaluate their priorities. If the patient perceives that she participates in decision making and that she is given as much information as possible, she will respond to the mutually derived treatment plan with lower levels of anxiety and depression, embracing it as a collaborative plan of action. She should be able to propose alternatives or modifications to the physician’s recommendations that reﬂect her own beliefs and attitudes. There is ample evidence that patient communication, understanding, and treatment outcomes are improved when
Table 1.2 Important Components of Communication between the Patient and Physician: The Physician’s Role
Table 1.3 Behaviors Associated with the 14 Structural Elements of the Interviewa
Preparing the Environment Negotiating a Priority Problem
Provide access Reach agreement on order of addressing issues
Eliminate distractions and interruptions Develop personal ways of asking patient to tell her story
Self-hypnosis Ask about entire course of illness
Constructive imaging Establishing the Life Context of the Patient
Let intrusive thoughts pass through Use first opportunity to inquire about personal and social details
Create a personal list of categories of observation Learn about patient’s support system
Practice in a variety of settings Learn about home, work, neighborhood, safety
Presentation Memorize complete review of systems
Affect Review issues as appropriate to specific problem
What is said and not said Presenting Findings and Options
Create a personal stereotypical beginning Ascertain patient’s level of understanding, cognitive style
Introduce oneself Ask patient to review and state understanding
Check the patient’s name and how it is said Summarize and check
Create a positive social setting Tape record and give tape to patient
Negotiate about differences in perspective Agree on what is feasible
Be sure expectations are congruent with patient’s Respect patient’s choices whenever possible
Detecting and Overcoming Barriers to Communication Closing
Develop personal list of barriers to look for Ask patient to review plans and arrangements
Include appropriate language Clarify what to do in the interim
Physical impediments such as deafness, delirium Schedule next encounter
Recognize patient’s psychological barriers, such as shame, fear, and paranoia
Develop personal methods of initiation of problem listing
Ask “What else?” until problems are elicited aLipkin M Jr. Physician–patient interaction in reproductive counseling. Obstet Gynecol 1996;88:31S–40S.