Communication is cornerstone of compliance, outcomes, no lawsuits

Yet, recent surveys show that patients believe the quality of this interaction is deteriorating - even as medical schools are emphasizing communication courses.

The reasons for the decline are multifaceted, says Beth Lown, M.D., assistant professor of medicine at Harvard Medical School and director of faculty development at Mount Auburn Hospital, Cambridge, Mass. They include changes in financing and payment structures that force physicians to see more patients in less time.

Real-life time constraints and other factors are straining important sharing of information between doctors and their patients, experts say.

And that can create difficulties at every step. Communication has been demonstrated empirically to impact almost every outcome in medicine, says Paul Haidet, M.D., M.P.H., staff physician at Michael E. DeBakey VA Medical Center and assistant professor of medicine at Baylor College of Medicine, Houston.

"The malpractice literature is fascinating, because, basically, the strongest thing that correlates with whether a malpractice case is brought or not is communication factors," Dr. Haidet says. "Whether or not there was actual negligence is poorly correlated with whether a case is brought or not. It is all about the communication."

Randomized controlled trials have shown that good communication patterns result in lower blood pressures among hypertensive patients, better diabetes control among diabetics, faster headache resolution in patients plagued by headaches, and more effective pain control in people with back pain.

"When communication is better, patients are generally more adherent with prescribed therapy," Dr. Haidet says.

Basic tenets

Experts say basic tenets of good communication apply across specialties.

What often happens in the medical encounter, they say, is that the patient's perspective gets lost. The conversation typically is about only the biomedical problem. For the best decision-making to occur, both perspectives - the medical considerations and the patient's perception of the illness - must inform the process.

"If I broke my arm tomorrow, it would be a major drag, but in my field, I can type with one hand and get around fine. If I were a concert pianist and I broke my arm tomorrow, that illness has a whole different meaning," Dr. Haidet says. "Both perspectives need to be shared and ... this is why communication skills training is important.

"Most doctors say they already know how to talk to people, and they do, if they have two hours with a patient," he says. "The real skill comes in ... when they have 15 minutes with patients. Being able to collect the biomedical information, make a differential diagnosis and understand the patient's point of view takes serious skill - skill that is not innate in our growing up as members of our culture."

One way to get the patient's perspective is to ask before you tell, says Bob Arnold, M.D., Leo H. Criep professor of medicine, University of Pittsburgh, Pittsburgh.

"Often, you can share your expertise about a patient's condition more successfully and succinctly if you figure out what the patient is thinking or what the patient's beliefs are first," Dr. Arnold says.

Understand that what you see is not necessarily what the patient sees, he says.