Economic status (e.g., poverty, insuredness)
Religion (e.g., religiosity, spirituality)
Culture and ethnic background (e.g., first language, community)
Career (e.g., work environment, satisfaction, responsibilities, stress)
The patient’s understanding of key events in the family medical history and how they relate to her is important. The patient’s sexual history, relationships, and practices should be understood, and her functional level of satisfaction in these areas should be determined. The physician should avoid being judgmental, particularly with respect to questions about sexual practices and sexual orientation (see Chapter 11).
Good communication is essential to patient assessment and treatment. The patient–physician relationship is based on communication conducted in an open, honest, and careful manner that allows the patient’s situation and problems to be accurately understood and effective solutions developed collaboratively. Good communication requires patience, dedication, and practice and involves careful listening and both verbal and nonverbal communication.
The foundation of communication is based on four key skills: empathy, attentive listening, expert knowledge, and the ability to establish rapport. These skills can be learned and refined (4,7,8). When the initial relationship with the patient is established, the physician must vigilantly pursue interviewing techniques that continue to create opportunities to foster an understanding of the patient’s concerns (9). Trust is the fundamental element that encourages open communication of the patient’s feelings, concerns, and thoughts, rather than withholding information (10).
One very basic element of communication—sharing a common language and culture—may be missing when a clinician interacts with a patient of limited or no English proficiency. Language concordance between physician and patient is assumed in many discussions of communication. More than 18% of Americans speak a language other than English at home, and over 8% have limited English proficiency (11). Language barriers are associated with limited health education, compromised interpersonal care, and lower patient satisfaction in health care encounters (11,12). Medical interpreters can mitigate these effects. The State of California recognized the importance of communication in patient–physician interactions through a provision in the Health and Safety Code that states “where language or communication barriers exist between patients and the staff of any general acute care hospital, arrangements shall be made for interpreters or bilingual professional staff to ensure adequate and speedy communication between patients and staff” (13). Training future physicians to work with interpreters is receiving increasing attention in United States medical schools and will contribute to improved clinical practice and reduce health care disparities (14).
Although there are many styles of interacting with patients, and each physician must determine and develop the best way that she or he can relate to patients, physicians must convey that they are able and willing to listen and that they receive the information with utmost confidentiality (1). The Hippocratic Oath demands that physicians be circumspect with all patient-related information. The Health Insurance Portability and Accountability Act (HIPAA), which took effect in 2003, established national standards intended to protect the privacy of personal health information. Initial fears expressed about the impact of HIPAA regulations and the potential for legal liability led to discussions of appropriate communication and physicians’ judgments based on the ethical principles of confidentiality in providing good medical care (15,16) (see Chapter 2).
Communication Skills It is essential for the physician to communicate with a patient in a manner that allows her to continue to seek appropriate medical attention. The words used, the patterns of speech, the manner in which words are delivered, even body language and eye contact, are all important aspects of the patient–physician interaction. The traditional role of the physician was paternalistic, with the physician expected to deliver direct commands or “orders” and specific guidance on all matters (4). Now patients appropriately demand and expect more balanced communication with their physicians. Although they may not have equivalent medical expertise, they do expect to be treated with appropriate deference, respect, and a manner that acknowledges their personhood as equal to that of the physician (17). Doctor–patient communication is receiving more attention in current medical education and is being recognized as a major task of lifelong professional learning and a key element of successful health care delivery (18).