Principles of Ambulatory Medicine, 7th Edition

Chapter 3

The Practitioner–Patient Relationship and Communication during Clinical Encounters

  1. Randol Barker

Each practitioner–patient relationship is established through person-to-person interactions in which the practitioner's goals are to obtain accurate and critical information from the patient and reach a valid formulation of the patient's problem or status; to provide information to the patient and ensure that the patient comprehends it; to decide on a management plan with the patient; to facilitate patient adherence to agreed-on plans; to attain mutual satisfaction with the relationship; and to alleviate the patient's symptoms. Achievement of these goals depends on the practitioner's knowledge of medicine, respect for the patient's participation in the interaction, and skills in communication and patient education. This chapter and Chapter 4 address the latter two issues.

The Practitioner–Patient Relationship

Types of Relationships

Our society's concept of the practitioner–patient relationship has evolved through the years. In 1951, Parsons described the patient's role as essentially passive (1). Later Szasz and Hollender (2) outlined the following three types of interactions between practitioner and patient: theactive–passive relationship, in which the practitioner has all authority (similar to Parson's conceptualization); the guidance–cooperation relationship, in which the practitioner still is somewhat directive and the patient cooperates; and mutual participation, in which there is active collaboration between patient and practitioner, and patients assume more responsibility for their care. The consumer movement of the 1960s and 1970s promoted the mutual participation relationship between practitioners and patients.

In the 1990s, the term patient-centered care was introduced to emphasize the primacy of the patient in the mutual participation model. It has been pointed out that the following are indicators of patient-centeredness (3, 4, 5):

  • Practitioner's goals that include learning and valuing the patient's personal illness story and reaching agreement with the patient on the meaning of the illness and on the management plan.
  • Grounding of the law and medical ethics in the concept of patient autonomy.

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  • Quality assessment that includes the patient's perspective as a fundamental component.
  • Consideration of these factors in planning health care education and research.

More recently, the term relationship-centered care was promulgated to delineate a relationship that integrates the perspectives and roles of both patients and practitioners and that broadens that relationship to include the dimension of self-awareness (6, 7, 8).

Ethical Aspects of the Relationship

The mutual participation model is central to the principles of medical ethics that have been delineated in the past two decades (9). These principles define a practitioner–patient relationship in which the practitioner respects the sanctity of the individual person and believes that that person's goals should be the basis for medical decisions. In practice, these principles require that practitioners learn what their patients’ expectations and goals are and that patients (or their surrogates) participate as fully as possible in decisions about their health care. Such participation requires that the patient be competent to consider a specific decision; that the patient receive sufficient information regarding available options, demonstrate comprehension of that information, and be given sufficient time to consider the options; and that the patient's decision be voluntary, that is, free from constraints imposed by the interests of other persons. Additional ethical principles that are critical in a respectful practitioner–patient relationship are truthfulness and protection of confidentiality.

Adherence to each of the principles of patient-centered medical ethics is not always possible or appropriate in ambulatory practice. For example, although patients generally want to be well informed, many still prefer to have their practitioner recommend choices (10). In addition, a practitioner's personal beliefs and standards of practice must be considered. If a patient requests a course of action that is contrary to the practitioner's beliefs or standards or that endangers others, the practitioner must indicate this to the patient and, if the patient's wishes cannot be accommodated, care should be transferred to another practitioner or to the court system. Challenging situations such as these are not uncommon in ambulatory practice (11).

For situations that involve patient competence, truth telling, confidentiality, and patient behaviors that may harm others, a practitioner–patient relationship that has been developed over time may make both prevention and resolution of problems more feasible. For example, an elderly patient may agree to discontinue driving and propose satisfactory alternatives in the context of a trusting relationship.

Problems caused by external factors, particularly the ground rules governing services covered under managed care plans, may also be amenable to resolution through the practitioner–patient relationship. Encouraging patients to become informed about the processes and guidelines of their health care insurance and offering other options when patients make unreasonable requests are examples of ways to include the patient in addressing such externally imposed challenges (see Managed Care and the Practitioner–Patient Relationship).

Involvement with Family Members and Significant Others

Commonly, a spouse, family members, or friends—especially those who are close to the patient during a period of illness—both want to know about the patient's condition and are affected by the patient's illness. Significant others may play an important role in determining the course of the patient's illness by sharing in decision making, providing support, or, at times, creating barriers. Consequently, developing a relationship with those close to the patient is a predictable and important aspect of the care of many patients. A practitioner's involvement with others may range from the brief exchanges that occur at the beginning or end of office visits to interactions during a planned family meeting (12). The skills for use in the traditional practitioner–patient dyad, described later, are the skills appropriate when others are included.

Special considerations for relating to family members and friends include the following:

  • Recognizing the impact on the patient's illness of patient–family dynamics and practitioner–family dynamics.
  • Avoiding breach of confidentiality by ensuring that the patient consents to inclusion of others in a visit; then, when appropriate, including others during all or part of the encounter.
  • Learning about and acknowledging the distress that the patient's illness has caused for those close to the patient.
  • Providing information and engaging in problem solving that will facilitate the roles of others in promoting the patient's health.
  • When appropriate, including family members in decision making.

Additional details about the positive and negative influences of family on a patient's health are found elsewhere in this text (see Social Support in Chapter 4).

Planned Family Meetings

There are a number of situations in which it is helpful to convene the members of a patient's family and, at times, others such as a nurse or social worker. Common examples include addressing end-of-life issues (see Chapter 13); addressing poor control of a chronic illness; decisions

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regarding a long-term care plan; substance abuse (see Family Intervention in Chapter 28); and marital or sexual difficulties or other family dysfunction (see Family Counseling in Chapter 20). Table 3.1 describes specific tasks that one should consider when planning and conducting a family meeting.

TABLE 3.1 Tasks to Consider for Planning and Conducting a Family Meeting

Premeeting Tasks
Clarify the purposes for the meeting.
Establish which family members, friends, or professionals should attend.
Set up the appointment, specifying the planned duration and location.
Develop a strategy for conducting the meeting, including specific questions, observations, or tasks that will facilitate addressing the purpose of the meeting.
The Five Phases of a Family Meeting
Phase 1: Socialize (Approximately 5 Minutes)
Greet each person attending the meeting.
State the purpose for the meeting, provide any crucial information that all need to know up front, and check briefly with each family member about themselves, their work, their relation to the patient, etc.
Phase 2: Set the Goals (Approximately 5 Minutes)
Ask the group, “What would you like to make sure we accomplish today?”
Restate each goal so it is clear, concise, and realistic; propose any important goals that the family has not mentioned.
Set priorities among the goals.
Phase 3: Discuss the Illness or Issue (Approximately 15 Minutes)
Elicit each participant's view of the illness or issue. Ask about past experiences or recent changes that could impact the issue of concern, such as moves, occupational changes, other illnesses, and deaths. Observe repetitive family interactional patterns. Final plans should not go against these patterns, unless specifically negotiated.
Encourage the patient and family to ask questions.
Ask how the family has dealt with similar illness or issues in the past.
Phase 4: Identify Resources and Ideas (Approximately 10 Minutes)
Identify family strengths and resources of all kinds.
Identify medical resources and community resources.
Phase 5: Establish a Plan (Approximately 10 Minutes)
Include resources and ideas that family members have suggested.
Negotiate a formal or an informal contract with the family. Have each person state what he or she will do.
Discuss any referrals, if relevant, at this point.
Offer to write down key information for family members.
Ask for any final questions.
Summarize the plan.
Thank everyone for coming and participating in the meeting.
Postmeeting Tasks
Write up a report of the meeting, including the attendance, the problem list, a global assessment of individual and family functioning, the family's strengths and resources, and the plan (both the medical regimen and the roles to be played by the patient and family members).

Adapted from McDaniel S, Campbell T, Seaburn D. Family oriented primary care: a manual for medical providers. New York: Springer-Verlag, 1990.

Sociocultural Diversity, Health Literacy, and the Practitioner–Patient Relationship

Sociocultural Diversity

A classic paper published in 1978 points out that predictably there are differences in the ways in which a practitioner and a patient think about and respond to the patient's medical problems (13). The sources of these differences range from the unique ideas of individual patients, not infrequently based on transgenerational family stories of illness (14), to ideas and behaviors particular to the social or cultural groups to which patients belong. The composition of the United States population in the year 2000, summarized in Table 3.2, indicates that patients with diverse cultural traditions are likely to make up an important proportion of the patients cared for by most practitioners. Many of these patients will be recent immigrants; Chapter 41 provides information about the regulations related to health assessment of new immigrants to the United States and about important considerations related to the health care experiences, traditions, and expectations

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of immigrants. In addition, the 2000 census found that approximately 18% of the United States population speaks a language other than English at home (15) and that 4.2% speak English poorly or not at all: 28% of Hispanics, 23% of Asian or Pacific Islanders, and 13% of Indo-Europeans (16).

TABLE 3.2 Profile of General Demographic Characteristics: United States, 2000

Subject

Number

Percent

Total population

281,421,906

100.0

Sex

   Male

138,053,563

  49.1

   Female

143,368,343

  50.9

Racea

   One race

274,595,6768

  97.6

      White

211,460,626

  75.1

      Black or African American

34,658,190

  12.3

      American Indian and Alaska Native

2,475,956

    0.9

      Asian

10,242,998

    3.6

      Native Hawaiian and other Pacific Islander

398,835

    0.1

      Some other race

15,359,073

    5.5

   Two or more races

6,826,228

    2.4

Hispanic or Latino (of any race)

35,305,818

  12.5

aThe concept of race as used by the Census Bureau reflects self-identification by people according to the race or races with which they most closely identify. These categories are sociopolitical constructs and should not be interpreted as being scientific or anthropologic in nature. Furthermore, the race categories include both racial and national-origin groups. From U.S. Census Bureau, Census 2000.

Health Literacy

Health literacy was recently recognized as a major factor in the quality of health and health care in the United States. Health literacy is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (17). A review of existing data suggests that limited health literacy is common—a prevalence of 22% to 29% for low health literacy and 16% to 23% for marginal health literacy (18). Limited health literacy is consistently associated with low education level, older age, and ethnicity (18). In 2004, in recognition of the importance of the issue, a national research program was initiated to determine the association of health literacy and quality of health and health care, and to delineate ways to identify and address limited health literacy (19).

Implications for the Practitioner–Patient Relationship

In a number of ways, the effectiveness of the practitioner–patient relationship may be enhanced, or diminished, depending on awareness of and response to differences between patient and practitioner. The following general approaches can enhance the relationship:

  • Learning and inquiring explicitly about the beliefs, values, and behaviors of the sociocultural group to which one's patient belongs. Common sources of group-determined beliefs and behaviors are religious tenets related to illness, traditional roles of family members in medical decisions, and folk healers. It has been pointed out that culture-based values regarding the following five factors may be fundamental to a person's health-related behavior: status bestowed on practitioners or family members, personal privacy, fatalism, importance of the individual and the group, and access to information. Additionally, patients may bring cultural preferences regarding communication content (e.g., topics appropriate to discuss, nonverbal cues) and style (e.g., directness, distance, touch, degree of formality, forms of address, pace, voice pitch) (see Gardenswartz and Rowe, Managing Diversity in Health Care, athttp://www.hopkinsbayview.org/PAMreferences).
  • Recognizing and reflecting about one's own beliefs, biases, and emotional reactions toward cultural and individual differences, and suspending judgment when possible.
  • Ensuring that an interpreter is present when there is a language barrier (see Chapter 41 for information about telephone access to interpreters).
  • Including culture-friendly objects and patient materials in medical offices, such as artwork that reflects different races, ethnicities, or sexual orientations, and patient instructional or educational materials written in different languages.
  • Inquiring of those at risk (e.g., low education level, elderly, ethnic subgroups) in a nonjudgmental way about health literacy, using phrases such as “Many people need the help of others to read or understand information about their medical care…instructions on medicine bottles, appointment letters, written materials about their illness and so forth. How often do you need help like that?” For those who report a need for help or who have limited health literacy, ensuring that they have access to someone, ideally a family member, who can read information that is important to their medical care.
  • Learning about, explicitly inquiring about, and accommodating patients’ explanatory models for their illnesses.

Patients’ explanatory models for their illnesses address the same issues as practitioners’ explanatory models: etiology, name of the illness, pathophysiology (“what is wrong”), expected course, treatment, and response to treatment (13). Often, there are differences in the two models based on the difference in perspective between patients and practitioners (Table 3.3). Both parties may inhibit the

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development of an effective relationship—practitioners by focusing only on abstract disease formulations to address each of these issues, and patients by dwelling on their own formulation of what is wrong and resenting their practitioner's apparent inattention to that formulation. By recognizing or exploring patients’ own explanatory models (and, at times, learning of conflicting beliefs about the illness held by others close to the patient), then coming up with mutually acceptable ways of accounting for and addressing the illness, practitioners are more likely to help patients who bring strongly held personal or cultural beliefs to the encounter.

TABLE 3.3 Summary of Common Differences in Explanatory Models between Western-Trained Practitioners and Traditional Ethnic Patients

Aspect of Model

Western Practitioner

Ethnic Patient

Etiologic Beliefs

Social causes of illnesses

Usually limited to stress model or attributed to paranoia

Many social indiscretions can cause illness; blaming of self or others for symptoms is common

Environmental causes of illnesses

Exposure to known pathogens, toxins, and social stress may cause symptoms

“Hot–cold” imbalance in the body caused by dietary indiscretions or drafts may cause symptoms

Belief that conditions of the blood cause illness

Limited to specific hematologic disorders or hypertension

Many “conditions” of blood can cause illness (e.g., “too thick,” “too slow,” “too little”)

Symptom Interpretation and Presentation

Altered states of consciousness (trance, visions, etc.)

Usually considered abnormal

Often considered normal, desirable

Attitudes toward pain expression

Stoicism expected unless complaints are congruent with clear organic pathology

Either total stoicism or emotional expression of pain is healthy and expected

Focus on physical symptoms (somatization)

May be considered as a psychiatric syndrome

Expected, proper way of expressing distress

Treatment Expectations

Who is the patient?

Individual is the focus of decision making and care

Family must be involved in decision making

Beliefs about self-medication and alternative practitioners

Considered potentially dangerous, undesirable

Common

From Johnson TM, Hardt EJ, Kleinman A. Cultural factors in the medical interview. In: Lipkin M Jr, Putnam SM, Lazare A, eds. The medical interview: clinical care, education, and research. New York: Springer-Verlag, 1995.

Racial and language concordance between patient and practitioner appears to correlate with more collaborative relationships (20) or better health care outcomes (21). This finding points to the importance of more diversity in the makeup of the practitioner workforce as well as the need for all practitioners to enhance their commitment to and skills for relating to patients in the context of sociocultural differences.

Managed Care and the Practitioner–Patient Relationship

The ways in which managed care may affect the practitioner–patient relationship have received much attention. Table 3.4 contains a summary of potential improvements and threats to the relationship that are associated with managed care. The authors considered the impact on factors key to the relationship (the six Cs): patient choice, practitioner competence, practitioner–patient communication, practitioner compassion for the patient, continuity of practitioners, and avoidance of conflict of interest (22).

In a thoughtful essay, Shorey captures much about the change that managed care has brought to the practitioner–patient relationship: From the need to build trust in the context of a dyad (practitioner and patient), practitioners need now to inspire trust in a context (managed care) in which they value dyadic relationships but also consider the health of all patients in their panels (23). A number of other authors have written helpful analyses of this topic (see http://www.hopkinsbayview.org/PAMreferences). In 2004, a working group of stakeholders (patients, physicians, managed care representatives, and medical ethicists) published a multicomponent statement of ethical principles for managed care (see Povar at http://www.hopkinsbayview.org/PAMreferences).

Communication During Clinical Encounters

The Functions of the Medical Interview

The following three functions, delineated by Lazare, Putnam, and Lipkin (24), are widely accepted as ways to describe what happens in medical interviews:

TABLE 3.4 The Effects of Managed Care on the Physician–Patient Relationship

Potential Improvements

Potential Threats

Choice

·   Expanded choice of managed care plans, particularly in areas with low managed care penetration

·   Expanded choice of preventive and pediatric services

·   “Cherry picking” increasing the number of uninsured Americans

·   Employers restricting patients' choice of managed care plans and physicians

·   Price competition forcing patients to choose between continuing with their current physicians or switching to a cheaper plan

·   Financial failures of managed care plans forcing change in managed care plan without choice

·   Restrictions by managed care plans of choice of specialists and particular services

Competence

·   Development and use of measures to assess quality of physicians and managed care plans

·   Greater use of preventive medical care

·   Underuse of specialists and specialized facilities

·   Unreliable and non–risk-adjusted quality measures providing a distorted view of competence

Communication

·   Increased number of generalists and primary care providers

·   Creation of physician–nonphysician provider teams to provide a broader range of providers knowledgeable about the patient's condition

·   Productivity requirements creating shorter office visits, reduced telephone access, and other access barriers to physicians

·   Advertising creating inflated patient expectations

Compassion

 

·   Less time for interaction with patients during stressful decisions

Continuity

·   Selection of a primary care provider encouraged (for patients who may never have had continuity of care by a single provider)a

·   Price competition forcing patient choice of continuity at a higher price vs. the cheapest plan

·   “Deselection” of physicians, disrupting existing physician–patient relations

·   Frequent changes by employer of managed care plans forcing changes of physician

(No) Conflict of Interest

·   No incentive to overuse or overtreat as exists in fee-for-service environmenta

·   Linking practitioner salary incentives and bonuses to reduced use of tests and procedures for patients

aAdded by the author.
Adapted from Emanuel EJ, Dubler NN. Preserving the physician–patient relationship in the era of managed care. JAMA 1995;273:323.

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  • Determining and monitoring the nature of the patient's problems
  • Developing, maintaining, or concluding the therapeutic relationship
  • Carrying out patient education and implementing a treatment plan

More recently, an overarching fourth function, partnership building, has been delineated (25). Partnership building refers to the many ways in which the patient's input is enlisted and respected in information gathering and decision making during a practitioner–patient interaction. One or more of these broad functions is central to all of the skills for practitioner–patient communication described in this chapter and inChapter 4.

Importance of Effective Communication

The importance of effective communication has been confirmed in a variety of studies of the practitioner–patient relationship. A large body of published research shows that effective communication skills correlate with obtaining valid information, getting patients to disclose fully the reasons for their visits, reported satisfaction with the practitioner, improved patient adherence to medical regimens, a reduced risk of being sued for malpractice (see Lipkin et al., The Medical Interview, at http://www.hopkinsbayview.org/PAMreferences), and higher physician satisfaction (26). A smaller body of literature also exists in which experimental studies, using control and intervention subjects, document

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the positive impact of effective communication skills on patient outcomes, including emotional health, symptom resolution, patient function, blood pressure and glucose control, and pain control (27).

Although gathering and providing of information may appear to be the primary reason for direct communication with patients, thetherapeutic nature of the interaction is perhaps the factor that is most important to the health of the patient. As summarized by Reiser and Schroder (28):

Repeatedly, practitioners will feel the power of something intangible, yet unmistakable, in the nature of the practitioner–patient relationship that helps a sick person to get better. It is hard to overestimate the potency and curative potential of this very unique and special relationship. For all our technical advances, this relationship remains one of medicine's most powerful therapeutic tools.

The skills that establish the therapeutic nature of every medical encounter are described here and in Chapter 4. Chapter 20 describes the important phenomenon of transference and additional skills that are useful when the primary purpose of the encounter is to deal with psychosocial problems.

The Patient's Experience during Ambulatory Encounters

The impact of communication during an ambulatory encounter is determined by the way both parties think about the encounter in advance and afterward and by the communication skills used during the encounter. The latter can be seen as skills that are useful for organizing the flow of the visit and skills that are useful throughout the visit (see next section).

Recognizing What the Patient Experiences

An interaction with a patient is likely to be more effective when, as much as possible, the practitioner recognizes the feelings and concerns that the patient brings to the visit and voices this to the patient. As discussed earlier (see Sociocultural Diversity and the Practitioner–Patient Relationship), this may include being aware of traditional beliefs and behaviors of patients from diverse cultural backgrounds (13).

It is important to realize what it is like for a patient to go to a practitioner. The way in which most patients think about a visit to the practitioner has been described as “expectant trust” (see Chapter 20). Patients may come with anxieties concerning what the practitioner will find wrong with them; they may come expecting the practitioner to help them solve one or more problems; or they may have any of a number of other types of expectations about the visit. Patients know that their practitioners have busy schedules, and some may be reluctant to ask what they think the practitioner will regard as trivial questions. Social distance often exists between practitioner and patient and, when combined with the practitioner's special knowledge, gives the practitioner considerable authority. As a result, patients may be reluctant to contradict or correct their practitioners’ statements, may misrepresent their thoughts or feelings to provide answers they think the practitioner wants to hear, or may not ask for clarification despite being confused by medical terminology. During the physical examination, some patients feel embarrassment at being exposed, and this may further inhibit disclosure of important concerns. Most patients, even those who have had a long-standing relationship with their practitioner, experience some of these types of discomfort during an office visit. It can help to ask oneself, “If I were this patient, how would I be feeling during this visit?” It is equally telling to ask oneself, after a visit, “If I were that patient, how would I be feeling about the visit when I have reached home?”

As discussed later (see Challenging Situations and Practitioner Self-Care), practitioners also bring expectations and vulnerabilities to encounters with patients. Awareness of these factors can be seen as an important skill that may determine the quality of communication during a visit.

Rapport

An aspect of the practitioner–patient relationship that especially facilitates disclosure of concerns by patients and readies them to make decisions is the development and maintenance of rapport. Rapport is a mixture of harmony and affinity felt between two or more people. Rapport is fostered with a knowing look or by voicing awareness of the patient as someone unique (e.g., “How's everything going since you moved from your house to an apartment?”). Rapport also develops when a patient feels that his or her input is respected and that the practitioner has empathy for the patient (see Addressing Emotions).

Skills for Organizing the Flow of the Visit

Given the limited time available for ambulatory visits, it helps to have a scheme for organizing the flow of a visit. The scheme described here emphasizes relationship-centered skills that are useful for each of the stages of a visit. The next section describes skills that may be helpful in any part of the visit.

Planning the Visit

It is helpful to review critical information in the patient's record before starting the visit. For an established patient, record review could include checking on the patient's social history, on preventive care due at this visit, or on issues

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addressed at the previous visit. This can be done before seeing the patient or just after the greeting (“Before we start, let me take a minute to get right up-to-date with what is in your chart.”). This planning ensures that the practitioner knows information that will help set the agenda for the visit, and it limits the need to look through the chart in the presence of the patient.

Opening the Interaction

Greeting a patient, shaking the patient's hand, using the patient's name, and, if it is a first visit, introducing oneself all make the patient feel welcome. The first few moments of first or second encounters are crucial because the practitioner and the patient are sizing up one another, and nonverbal behavior often takes precedence over what is being said. Both practitioner and patient are paying attention to physical features, type of handshake, voice tone and pitch, age, dress, and overall demeanor.

The seating arrangement of the office can affect the development of rapport. When the patient's and the practitioner's chairs are arranged so that the two are facing one another without the full breadth of a desk interposed, a patient may feel less intimidated than when facing a practitioner across a desk.

Exploratory Information Gathering

For gathering information about a patient's problems, it helps to begin with an exploratory approach and to ensure that the patient knows that this is one's intent. Exploratory interviewing combines open-ended phrasing of questions and allowing a patient to respond without being interrupted. An exploratory approach is the most efficient way to learn what the patient knows, and it indicates interest in the patient from the outset. Asking the patient, “How have you been doing since your last visit?” is an appropriate open-ended question for a planned followup visit. For a new-patient visit or a visit requested by the patient, the practitioner will want to explore the reason for the visit by saying, “Please tell me what brings you in today.” This type of phrasing provides an opportunity for the patient to describe the reasons for the visit and does not imply that there is a problem.

Agenda Setting

In response to the opening inquiry, the patient's response might be, “Well, I haven't been doing so well lately. My shoulder has been giving me a problem.” Before exploring the first problem mentioned, it is helpful to establish whether there are other issues that the patient wants to address during the visit (e.g., “Before we talk about your shoulder, is there anything else?”). If one assumes that the patient wishes to discuss only one problem and proceeds to explore that problem, the patient may mention other problems whenever there is an opportunity, often when one is preparing to close the visit. The practitioner should also name items to be added to the agenda (e.g., “I also want to get up-to-date on your smoking.”), then restate the issues to be addressed during the visit. If too many issues are identified, it is appropriate to ask, “Which problems seem to be bothering you the most?” and mutually to prioritize those issues to be addressed at the visit.

Getting the Patient's Story

After agreement on the agenda for the visit, the practitioner continues to explore the problems one at a time. “Tell me about the shoulder pain” would be a clear invitation to the patient to describe the problem in his or her own words. When patients give the history in their own words, the length of the interview does not increase (29) and they are more likely to explain why a problem concerns them (e.g., “With spring coming, I’m thinking that I might have to give up tennis altogether because of the pain.”).

If an exploratory approach is maintained, a patient's medical problem usually emerges as part of a meaningful personal story (4,30). For example, the patient's concern that a shoulder pain means that he or she will never play tennis again may be founded in the experience of the patient's father years before—a personal story that would clarify the importance of the symptom to the patient and would be crucial to consider in the closing part of the visit (see later discussion). In addition to bringing out important information, an interview that allows emergence of a patient's personal story invariably contributes to the development of rapport.

Exploratory questions can be used throughout the interaction. When the patient produces information that needs clarifying, additional exploratory questions are helpful to establish a common meaning. For example, if the patient has named “constipation” as a new concern, it helps to explore what this means to the patient (e.g., “Tell me what you mean by constipation?”). One may discover that the patient has a bowel movement every other day and yet believes that this means constipation.

Clarifying and Hypothesis Testing

Not visible to the patient, but constantly operating during an interview, is hypothesis testing by the practitioner. Because exploratory inquiry rarely provides all of the information needed to evaluate a problem, it is usually necessary to use focused questions to fill in gaps and narrow the differential diagnosis. Table 3.5 lists generic information that is important in assessing most problems.

Direct or focused questions are questions phrased to clarify specific facts, such as, “When did you first notice the pain?” or “What words would you use to describe the pain?” or “Can you show me with your hand where the pain is?” When seeking such specific information, it is important to avoid asking leading questions—questions that

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tend to elicit predetermined answers, usually in the form of a simple “yes” or “no.” For example, the following question, presumably related to a hypothesis that has occurred to the practitioner, is a leading question: “You don't have the pain every day, do you?” This leading question gives the message to the patient that the practitioner does not expect the pain to occur every day. Patients who are somewhat passive may agree to whatever their practitioner suggests, even if the answer is inaccurate. Once a patient has responded inaccurately, the patient may become distracted and forget to report important information.

TABLE 3.5 Generic Information Important in Assessing Most Problems

Chronology of symptoms
   Onset of problem: since when?
   Frequency
   Duration of an episode
   Temporal trend: unchanging, better, worse
   Past history of similar problem: when, etc.?
Quality of symptoms
   Severe to not severe
   Quality consistent or variable
   Location, radiation (if pertinent)
   Patient's own words to describe quality
Description of one episode (for recurring symptom)
Associated additional symptoms
Factors, circumstances that aggravate symptoms
Factors, circumstances that alleviate symptoms
Remedies or measures tried
Impact of symptoms on valued activities
Patient's explanatory model for symptomsa
Fears or concerns caused by symptoms

aSee page 29 and Table 3.3.

When a patient cannot provide needed information, it sometimes helps to offer a number of choices from which to select. For example, if the patient reports chest pain but is unable to provide accurate information about whether the pain radiates, the practitioner might ask, “Does the pain seem to go anywhere else, such as to your back, one of your arms, your neck, or your legs?” Although the practitioner may have an idea of the likely response, this will not be obvious to the patient because the patient is given several choices. In contrast, a question such as, “Does the pain move to your left arm?” is a leading question, giving the patient the impression that this is the correct answer.

A patient will at times give a vague, aggregate description of an episodic symptom. In this situation, it is helpful to have the patientdescribe in detail a single episode, for example: “Tell me about the last time you felt the nausea and crampy pain.” This technique clarifies the nature of the symptoms, and, importantly, it often brings to light social or environmental factors important to the problem (e.g., “Well, the last bad headache was Saturday. Yeah, my teenage son had stayed out all night.”).

When asking direct questions, it is important to ask only one question at a time and to phrase each question so that it refers to one piece of information. Thus, when the patient responds, the practitioner knows to what the patient is referring. For example, to questions such as, “Are you having any problems sleeping or eating?” or “Are you constipated or do you have diarrhea?” a positive response may not reveal which is the problem. Conversely, a negative response may refer to only one of these problems.

While responding to questions, the patient may give verbal cues related to the discussion or concerning other issues that need exploration. At times it is appropriate to pursue a verbal cue when it is uttered; at other times it is more appropriate to acknowledge it and let the patient know that you will return to it later. If a verbal cue is pertinent to the present discussion, it is helpful to repeat the patient's words or to explore what the patient means. For example, in response to a question about pain, a patient may respond, “Well, it seems to have gotten worse lately, but maybe it's just my nerves.” Here, an appropriate response would be an open-ended question such as “Your nerves?” or “What do you mean?” The following response to a question about sleep quality in a patient with pain is an example of a verbal cue that one would explore separately: “Sometimes I wake up in the middle of the night, but it isn't because of the pain.” Depending on the hypothesis that one is testing regarding the patient's pain, it might be more appropriate to pursue the sleep problem later in the interaction.

A patient's nonverbal cues can also provide important information. A patient's vocal message—including pitch, tone, and tempo—may confirm or contradict the content of the patient's verbal message. Nonverbal cues also include body language. Elements of body language that can be observed are the patient's sitting position (e.g., sitting on the edge of the chair suggests apprehension, facing away from the practitioner suggests mental discomfort), head position (e.g., held back in defiance, anxiety, or fear; held down or turned away in sadness, shame, or denial), facial expression (eyes, eyebrows, and forehead show the greatest range of emotions, including surprise, fear, anger, happiness, disgust, sadness), hands (e.g. wringing or rubbing of hands can show anxiety; clenched fists may signify anger), and arms and legs (e.g., crossing of the legs, and especially the arms, can signify resistance, defensiveness, or discomfort). At times, incongruity between what the patient says and the patient's voice quality or body language is the only indicator of an important problem that the patient is hesitant to disclose.

Carrying Out Patient Education, Choosing a Treatment Plan, and Closing

Telling the patient one's formulation of a medical problem and reaching consensus on next steps are the final phases of an ambulatory encounter. Because ambulatory

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patients are by definition quite autonomous, the skills needed in these phases are uniquely important in ambulatory care. Chapter 4, in the section entitled “Patient Education and Promotion of Healthy Behaviors,” describes in detail the principles and skills for addressing this part of the visit.

At the close of a visit, it is important to accomplish a number of concrete tasks:

  • Schedule a followup visit at a mutually agreed to interval.
  • Instruct the patient to telephone back (or tell the patient that you or someone from the office will telephone) when this is indicated.

At this point, the physician should reemphasize his or her interest in the patient. Actions such as shaking the patient's hand or touching the patient on the shoulder, using the patient's name, ensuring that the patient has one's professional card, reminding the patient of night and weekend coverage, and encouraging telephone contact for interval problems convey the physician's interest to the patient.

Skills Useful throughout the Visit

A number of communication skills, described here, may be useful in any part of an ambulatory visit.

“Road Signs,” Summarizing, Vocabulary

“Road signs,” summarizing, and affirmative vocabulary help patients to participate effectively in the visit. These may include the following:

  • Using orienting and transitional statementsto ensure that the patient understands when the focus of the interview is changing (e.g., “At this point, I would like to learn more about your day-to-day activities.”).
  • Naming, then addressing, one problem or issue at a time(e.g., “Now, about your shoulder pain…” or “The medicine that I will prescribe…”).
  • Summing up and checking periodically(e.g., “So far, what I understand about your trouble sleeping is that…”), which lets patients know that one has heard what they said and gives them the chance to clarify or expand on important information.
  • Using vocabulary consistent with the patient's backgroundand avoiding formulations that may confuse the patient (e.g., telling a patient that test results are “negative” may convey to the patient that something is wrong).

Noting the Patient's Educational Needs

Patient education can be addressed most efficiently by ascertaining the patient's educational needs throughout the interview—by hearing or asking what the patient knows or wants to know about issues as they come up—but deferring the process of providing information and working out a plan to the latter part of the visit. It helps to give the patient a road sign (e.g., “When we finish up your visit, we will go over several things you can do to lose the weight you have gained.”). (See details in the schemes described in Chapter 4.)

Using Eye Contact

The eyes are a primary medium of expression, and they often tell more about a person's message than words do. Maintaining eye contact and communicating with one's eyes at the same level as the patient's (e.g., both parties seated) are basic to patient comfort. Looking at one's watch or at the chart while discussing a patient's problem may indicate to the patient that the practitioner is not listening, is not interested, or is too busy to answer questions that the patient may already be reluctant to ask. Although eye contact is one of the best ways to convey interest, staring can be uncomfortable and should be avoided.

Addressing Emotions

Predictably, patients experience one or more emotions before, during, and after visits to the practitioner. During visits, patients may or may not disclose their feelings. Empiric studies show that patients usually do not express emotions directly but through verbal or nonverbal clues (e.g., “It's been kind of different for me lately”; looking down or away when emotions are present) (30,31). A number of communication skills can facilitate disclosure and addressing of emotions (Table 3.6). Three basic reasons for addressing emotions are that patients usually feel better when they know that the practitioner is aware of their feelings; patients may be more able to concentrate and make decisions after an emotional state such as anxiety, sadness, or anger has been addressed, even briefly; and expressing emotions may be therapeutic for a patient.

Skills Related to Physical Examination and Documentation

Physical Examination

Appropriate communication during the physical examination includes describing what one is doing, obtaining further history when examining the location of a symptom, and avoiding the tendency to give important information (diagnosis and plan) during the physical examination or when the patient is getting dressed; in both instances the patient is distracted and cannot be expected to focus on the practitioner's message or to formulate questions as well.

TABLE 3.6 Skills for Addressing a Patient's Emotions

Skills for Facilitating Disclosure of Feelings
Explicitly Ask or Encourage Patient to Express/Clarify Feelings/Concerns
Restate patient's words about how the patient feels (e.g., “You feel down…?” repeated immediately after the patient says these words).
Acknowledge or probe feelings that seem to be present or just under the surface (e.g., “I notice you're getting tearful.” or “How do you feel about…?”).
Clarify or check feelings that patient has disclosed (e.g., “Let me see if I can better understand what you are feeling.”).
Allow Patient to Express Feelings/Concerns
Be attentive, do not interrupt.
Allow silence while patient prepares response or experiences emotional reaction.
Skills for Responding to and Supporting Patient
Convey Concern for and Interest in the Patient
Explicitly by saying so (e.g., “My concern is to help you get well.”).
Implicitly by remaining attentive, facilitating disclosure, indicating that the patient has been heard (e.g., by mentioning aspects of patient's life affected by an illness or by changing facial expression and vocal tone).
Communicate Understanding of Patient's Feelings (Empathize)
Name patient's feelings/situation (e.g., “Sounds as if you are pretty angry.”).
Check accuracy of naming (e.g., “Is this the way you experience it?”).
Use facilitative utterances (e.g., lower voice, use appropriate utterances such as “uh huh” that indicate that the patient is being attended to).
Legitimize Patient's Feelings/Thoughts/Actions
Indicate that patient's emotions/thoughts/actions are understandable and “normal” under the circumstances (e.g., “It's understandable that you feel this way.” “Many would have done as you did.”).
Convey Respect for the Patient's Efforts, Ideas
Compliment patient for whatever patient is doing well or plans to do (e.g., “Your decision to join Weight Watchers sounds good to me.” “I can see that you have given a lot of thought to.…”).
Respond Nonjudgmentally
Do not impose your own bias, values, or assumptions on patient characteristics or actions that evoke negative stereotypes or disappointment.
Nonverbally: Do not give negative message (e.g., nodding head disapprovingly, sighing in frustration, when a patient reports noncompliance).
Verbally: Do not imply that patient is “flawed or bad” (e.g., “That's alcoholism for you.…” or “Didn't you realize that if you ate crabs you'd put yourself into heart failure again?”). Instead, acknowledge that you have heard the patient's story.
Respond Nondefensively
Do not respond to patient anger or criticism by defense of performance; instead, acknowledge anger/criticism and try to address the reasons for the patient's behavior and concerns.
Admit mistakes, apologize when appropriate, be open to considering second opinions, and avoid self-righteousness.
Use Self-Disclosure Effectivelya
Reveal information about yourself, when appropriate, to convey support or empathy to the patient (e.g., “I felt the same way after I lost my mother.”).
Assure Partnership/Support
Make statements using the first person that assure support to the patient and convey the sense of partnership (e.g., “I will be with you throughout this illness.”).

aPreliminary findings from a large sample of primary care visits suggest that some patients may rate the visit less positively when physician self-disclosure occurs (32).

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Documentation

Dictating or writing a visit note can be done in a way that does not diminish rapport with the patient. It is helpful to point out that one will be making a few notes during the visit. It is equally helpful to suspend the interaction briefly while focusing on one's note, because this is a time that requires thought as well as writing or dictating. Dictating the note with the patient present may contribute to the goal of including the patient in all aspects of the encounter. In addition, offering to provide to the patient a copy of the encounter note has been suggested as a means of strengthening the practitioner–patient partnership (33).

Challenging Situations

All practitioners have been faced with challenging patients in medical practice. Patients may be challenging to care for because of their style of communicating; because of the overwhelming nature of their problems; because of their failure to adhere to health-promoting treatment or

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behavior; because they present psychosocial distress through somatic symptoms; because they do not respond positively to the practitioner's efforts; or because they have lifelong maladaptive personalities. Approaches to dealing with situations that may be difficult for practitioners are covered in Section 3 of this book, “Psychiatric and Behavioral Problems,” and in chapters describing patients who do not adhere to health-promoting behaviors (Chapter 4); adolescent and geriatric patients (Chapters 11 and 12, respectively); patients who have illnesses that create major psychosocial stress, such as cancer (Chapter 10), terminal illness (Chapter 13), human immunodeficiency virus infection (Chapter 39), diabetes (Chapter 79), or epilepsy (Chapter 88); and patients with myocardial infarction (Chapter 63) or stroke (Chapter 91).

TABLE 3.7 Common Negative Responses of Physicians to Difficult Patients and Strategies to Cope with These Responses

Physician's Emotional or Behavioral Reaction

Coping Strategiesa

Avoidance

Analyze why; attempt to understand and master feelings that lead to avoidance; stay with the patient; discuss with colleagues.

Identification with patient

Recognize, avoid tendency to deny seriousness of disease or to give way to despair; stay with the patient.

Hostility/rejection

Acknowledge and analyze; do not attempt to like the unlikable patient; use behavioral approaches; if situation is intolerable, transfer patient to another physician.

Feelings of impotence, inadequacy (e.g., in caring for dying patient)

Discover areas in which help and comfort can be rendered, both physical and emotional; be realistic about limitations to medicine; give the patient time to go through the stages of dying or bereavement.

Feelings of loss of control or threatened authority

Acknowledge and analyze; be realistic about personal limitations and actual range of influence and authority; be aware that patient's need for control over his or her own body may conflict with physician's urge to control the situation.

Frustration, confusion, uncertainty about dealing with the patient; coping strategies not effective

Request psychiatric consultation/referral.

Anxiety, guilt, frustration about meeting patient's recognized emotional needs

Allocate time realistically according to need; request consultation/referral.

aSee also skills in Table 3.6 and Psychosocial Treatment Techniques in Chapter 20. From Gorlin R, Zucker HD. Physicians' reaction to patients. N Engl J Med 1983;308:1059.

Practitioners predictably react emotionally to difficult patients and situations. Often, these reactions are evoked by patients’ feelings that seem to be directed personally at the practitioner; at times they are caused by recapitulation of aspects of the practitioner's own relationships (see discussion of countertransference, Chapter 20). Awareness of these feelings sometimes provides clues to a patient's diagnosis (e.g., sadness or feeling drained—depression, frustration—somatoform disorder) and provide the opportunity for reflection and behavior adjustments that can improve practitioner–patient rapport and optimize management (7,34).

Table 3.7 summarizes common negative responses of practitioners to patients and strategies for dealing with these responses. Most of the strategies require one to take time for self-exploration, one of several strategies that practitioners identify as healthy adaptations to stress (see next section).

Practitioner Self-Care

An unstated assumption about the practitioner–patient relationship is that a practitioner is always ready to respond with skill and concern to a patient's distress. Because of the extraordinary needs of sick patients and the demands of running a practice, most practitioners are at risk for experiencing excessive stress themselves, beginning during training and spanning their professional careers. Substance abuse, mental illness, family dysfunction, and loss of satisfaction are well-recognized accompaniments of practitioner stress. To counterbalance the risk of excessive stress and to increase the likelihood that they will be skillful, caring, and satisfied in their professional relationships, practitioners need to address the care of themselves.

When asked about their healthy approaches to stress, practitioners identify the following personal strategies, each of which should be available to most practitioners (34,35).

Values Clarification and Time Management.

This strategy, although it is implicitly present in each person's life, can be especially helpful when it is undertaken explicitly by professionals such as practitioners, whose working days often bring more demands than they can reasonably meet. The process of thinking about and writing down one's core values can help to identify activities that do or do not

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reflect those core values and to rearrange one's priorities. A common example of the impact of value clarification is the decision of an overcommitted professional to refuse, delegate, or discontinue low-priority activities so that more time can be allocated to valued family activities and personal life.

Self-Awareness and Sharing Feelings with Others.

These strategies may be important for addressing stressful situations, which may range from patient care encounters that evoke negative responses (Table 3.7) to family tension caused by the demands of one's professional life. One can incorporate these strategies by reserving time to reflect privately or to write a personal journal. And if one has a group of like-minded colleagues, one can schedule regular meetings at which to share, in confidence, one another's dilemmas and joys (35) and to better recognize feelings and responses, such as those listed in Table 3.7. The latter strategy is especially helpful for dealing with the negative effects of reflecting alone on stressful issues.

Personal Health Care.

The strategies in this section can be seen as ways to promote and protect one's mental well-being. It is equally important for practitioners to identify goals for their physical health and to address these goals with concrete measures such as exercising regularly, getting adequate sleep, avoiding harmful health habits, selecting and visiting a personal practitioner, and taking sick time when not well enough to work.

A 1997 multiauthor paper provides extensive information related to practitioner self-awareness and self-care (34).

Specific References

For annotated General References and resources related to this chapter, visit http://www.hopkinsbayview.org/PAMreferences.

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  15. U.S. Bureau of the Census. Profile of Selected Social Characteristics: 2000 (Table DP-2). Available at:http://www.factfinder.census.gov.
  16. U.S. Bureau of Census. Ability to Speak English: 2000 (Table QT-P17). Available at: http://www.factfinder.census.gov.
  17. Ratzan SC, Parker RM. Introduction. In: Selden CR, Zorn M, Ratzan SC, et al., eds. National Library of Medicine Current Bibliographies in Medicine: Health Literacy. Vol NLM, Pub no. CBM 2000-1. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services, 2000. Available at: http://www.nlm.nih.gov/pubs/cbm/hliteracy.html. Last accessed January 15, 2004.
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