MD/patient communication styles often worlds apart
Effective discussions about risks are essential
Ask many physicians about informed consent and often you’ll find they consider it a concept clear in ethics texts, but murky in practice. How many times have they labored to extensively explain the associated risks and benefits of a particular procedure or course of treatment to a patient only to hear the reply, "Whatever you think is best, doc"?
Effective communication is essential to accurately conveying information about risk, which is essential to informed consent for medical treatments — which, in turn, is essential to shared decision making in health care.
The problem is that physicians and patients often figuratively are speaking different languages, says John Paling, PhD, research director of The Risk Communication Institute in Gainesville, FL.
"In every other field or industry we recognize that risk communication can be very confusing. In every field where risks have to be communicated to the public — the food and drink industry, chemical and nuclear industries — we have decided that only a limited number of people should be doing risk communication and they should have special training to do it," he notes. "But, when you look at health care, every clinician, every genetic counselor who faces a patient is doing risk communication, but very few have any training."
In his upcoming book, Medics are from Mars, Patients are from Pluto, Paling examines some common differences in the way physicians and patients communicate and offers advice for helping clinicians cross the divide. In an article in the September 2003 issue of the British Medical Journal, he also emphasizes how improved communication strategies can help patients get a truer picture of the risks they face.1
First, it’s important to realize that most patients will make decisions based on emotional perceptions more than on hard numerical data, and they need their caregivers to provide information in a way that takes this into account and helps them put information into perspective, he adds.
Surveys of patients and physicians have found that their definitions of what makes a physician a good doctor are vastly different.
Ask most physicians the traits they most admire in their peers and you will hear references to the person’s level of education, where they’ve studied, how many articles they’ve published, etc. Ask patients the same question and most will respond that they value a physician’s ability to convey information in an understandable way, the willingness to answer questions, and how comfortable they are talking with him or her, Paling says.
Information vs. data
Too often, physicians tend to give patients data about the risks of a certain procedure — numerical odds about the chances for complications or for a poor outcome. But many people, and sometimes physicians themselves, have a difficult time placing the numbers into a context that enables them to make a decision.
But even when the data are put into context, they often are difficult for patients to comprehend. Many patients don’t understand fractions and are put off by large numbers.
"We know very well that if I say you have a 97% chance of survival, you will probably have a procedure. If I told you there was a 3% chance you would die, you likely would not [have the procedure]."
Paling recommends using visual aids to convey information about the risks and benefits of a particular course of action. He has designed a form, known as a Paling Palette, which allows physicians to visually demonstrate fractions in a way that people can easily grasp.
The palette is a graph depicting figures that represent 1,000 people. In discussing the chances that a 39-year-old pregnant woman will have a child affected by Down’s syndrome, the doctor can color in 12 of the figures to represent 1.2% (12 out of 1,000). In a separate color, however, the physician can also mark the four out of 1,000 women who have a miscarriage as a result of amniocentesis. In this manner, the patient can visualize the overall risk of both choices.
"The nice thing about the palettes is they show both the positive and the negative at the same time," Paling says. "You can see the 12 people who will be affected by this, but you also see the 988 who will not."
Discussions about whether a particular treatment is high or low risk often are not helpful because what one person perceives as an acceptable level of risk might not be acceptable to another, he says.
Some simple strategies often taught to risk communicators also can be helpful in communicating information about risks in the health care setting, Paling adds. For example:
- Don’t use descriptive terms alone.
- Show the numbers of the likely odds of an event in a visual context, and use a consistent denominator. Don’t use, for example, a risk of one in 500 for one outcome and one in 1,000 for another. Some patients will actually perceive the risk of one in 1,000 as greater because of the larger number, Paling says.
- Use standardized vocabulary.
- Use absolute numbers as opposed to relative risks, such as "three times as many patients were cured with Approach A compared to Approach B" can be easily misinterpreted, Paling says.
Using visual tools also allows the physician and patient to take a more collaborative approach to making a decision, rather than having the physician present information and then wait for a response/ decision from the patient, adds Paling.
"Using some simple shared thing, even just a piece of paper with some information on it, enables doctors to sit side by side with them and discuss the issue. That increases the patient’s sense of the physician’s caring and willingness to be a partner in the decision making," he says. "I call it a social lubricant."
Building a collaborative relationship with the patient is key to opening up effective lines of communication, agrees Steve March, executive director of the American Academy on Physician and Patient in St. Louis.
Formed almost 20 years ago, the academy sponsors research in physician-patient communication, advocates improved communications education for medical students, and offers continuing education in communications strategies for physicians.
"We have learned that the relationship between the physician and the patient is extremely important," March says. "And we know that the most effective approach is when the physician and patient work together in partnership; patients share information more effectively when they feel a connection."
When explaining a difficult diagnosis to a patient, doctors often get carried away using specialized terminology that may be familiar to them, but meaningless to patients, March adds. A more useful approach involves paying attention to the patients’ existing knowledge, what the patient is feeling, what they believe, and what expectations they have, and presenting information that takes all of these factors into account.
"For example, if a person is shocked by hearing a diagnosis, their feelings become the immediate priority. Pressing forward to share more information at that moment can be pointless."
It also can be helpful to take a negotiating approach with the patient, he adds.
"Simply telling someone to do something can be ineffective," March explains. "Asking what they’ve already tried, asking if the plan sounds workable, and asking about what’s important to them can be very effective in making a plan that the patient is invested in following."
Listening and building a relationship are keys, he adds. Physicians should use posture, eye contact, tone of voice, or gestures that help the other person feel at ease and more willing to share and discuss information about their condition.
Competence + caring = trust
A collaborative partnership can foster the trust necessary for patients to appropriately consider and participate in health care decisions, say both Paling and March.
In order for patients to trust their physicians, they first must believe that their doctor is caring and competent, Paling says.
"If you display competence without caring, you may have the patient’s respect but not their trust," he says. "And of course if you care a lot, but don’t display competence, that is not likely to inspire trust."
March once observed a physician’s discus-sion with a patient who had a mental illness. Although regular medication had been controlling the woman’s symptoms, it also caused some serious side effects, and she came to the doctor saying she no longer wanted to take the medication.
"Instead of immediately making the case for why she had to take the meds, the doctor simply asked why she wanted to discontinue," he says. "The patient talked about the side effects — she wasn’t treatment resistant or any such thing — she had a life to live and the side effects were interfering with it. The doctor went another step and surprised me by asking, What do you want to do?’"
After the patient explained that a different medication she had taken before didn’t have the same side effects, the doctor was able to transition her back to that medication.
"In this instance, it made sense, and he agreed with the decision," March says. "These two had a relationship and were truly communicating. It was also fast. This makes a point about the time crunch that most physicians are facing and the ability to still take the time to build a relationship and listen. It pays off."
1. Paling J. Strategies to help patients understand risks. BMJ 2003; 327:745-748.
- The American Academy of Physician and Patient: www.physicianpatient.org.
- The Risk Communication Institute: www.trci.info.
- John Paling, PhD, Research Director, The Risk Communication Institute, 5822 N.W. 91st Blvd. Gainesville, FL 32653.
- Steve March, Executive Director, American Academy on Physician and Patient, 1000 Executive Parkway, Suite 220, St. Louis, MO 63141.