PATIENT PROVIDER
COMMUNICATION
By Erin Wardlaw, RN; John Elder, PhD, MPH; Katherine Elder, PhD, MPAff
Communication between patients and providers can be challenging to both the sender and receiver. It is important as Public Health professionals to understand how providers communicate with their patients, and how we can help bridge gaps in communication and understanding in order for patients to utilize health care resources appropriately. If we consider health care as a ‘foreign language’ in itself, we can begin to recognize where communication strategies play an important part in the livelihood of patients. First, let’s view a dramatized example of failed health communication. Where did this communication break down? Was it the fault of the physician or patient? What outcomes should we expect?
Part One: Identifying Barriers to Health Communication
It may be easy to find certain barriers to health communication, but others are easier to hide or mask. Also, barriers are not singular but instead represent a complex combination of barriers interpersonal communication challenges in a given situation. Below is a list (by no means exhaustive) of how some common barriers to effective patient-provider can affect communication.
1. Spoken Language- When a patient and a provider speak two different languages, there are certain part some or even most of their communication that may be lost. It is typically required for hospitals in the USA to have a translator who is knowledgeable of medical terminology in both languages who can translate important health communication. However, this is not always plausible in doctor offices, clinics, or other settings in which the patient speaks a language that is nor widely shared locally.
2. Disabilities- There are many disabilities and impairments that can affect communication. This can range from intellectual and developmental, to physical (speech or hearing impediments), cognitive, and mental emotional.
3. Cultural considerations- The health beliefs and behaviors, preferences, communication norms, and prioritization of needs of an individual are all affected by culture, even when the patients and providers have a common spoken language. The understanding of physical and mental illness can also vary significantly across cultures due to religiosity and fatalism, beliefs in homeopathic treatments, reliance on friends and relatives for medical information, and other factors. This may result in underreporting of symptoms like pain and difficulty in discussing sensitive topics, among other issues.
4. Family involvement/ influence- Among cultural issues are patients' family member dynamics and those of their support network that affect communication. This can be complex at times when there are many different people involved in the care of a patient. Think of adolescent coming in for birth control and the presence of one or both parents. For example, if the mother is were present in the appointment, she may be dominating the conversation, steering, etc and impact the ultimate clinical decision.
5. Education- This can create patients who are minimally educated may encounter multiple barriers in to health communication. Some individuals have different low reading and literacy levels, literacy in general, some while others may come from have a university education even with a some health background and understand health communication more, or you may be dealing with a completely layperson, and will have to adjust how you explain things to them.
6. Health literacy- Is the degree to which individuals have the capacity to obtain, process, and understand basic print and other health information and services needed to make appropriate health decisions. Watch some compelling examples of how health illiteracy can impact the health of patients. Thinking of one or two of the vignettes, what is the likely health outcome for these patients?
Analysis Activity 1
Anonymously with respect to any individuals mentioned, write briefly about potential issues of using you, a family member, or a friend to translate important medical informaion to a relative who is a patient.
Analysis Activity 2
Read through one or more case examples ("patient stories"). Choose 1 case example and discuss what barriers were present and what was done to create better communication. Is there anything else you would have done in response to this patient?
Research Activity 1
By searching the Internet, find one credible source of health information and one non-credible source. Compare the two. What makes one credible and not the other? How could a layperson or patient distinguish the difference? What if the person was communicating with one of the barriers discussed previously- what could be a possible effect of them receiving information from the non-credible source? (Please refer also to the Source module of The Global Communication Project.
Part Two: Four Models for Patient-Provider Communication
There are many different models available to help aid communication in healthcare settings. Below are a few models for guiding communication that are researched and evidenced-based practice guidelines. Many are used in hospital communication with patients, providers, and interdisciplinary team. It is important to be aware of them, but as Public Health Professionals, some of these may be less applicable to you in non-hospital settings. Critical dimensions of these five models understandably overlap, yet each offers unique ideas and skills as well.
The strengths and primary functions of each of these models are as follows:
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RESPECT: Values and cultural awareness that clinicians should embrace.
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SBAR: Organizing *multidisciplinary) clinical team discussions of individual patients, and generating recommendations for actions.
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AIDET or Smith's 5 Steps: Step-by-step approaches to conducting patient interviews, concluding with recommendations for treatment and other actions.
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Teachback: Ensuring that the patient understands and is able to use the information that derives from the recommendations that emerge from the SBAR and AIDET/5 Step discussions.
RESPECT
The acronym “RESPECT” stands for Rapport(Respect), Empathy, Support, Partnership, Explanation, Cultural Competence, and Trust. This model represents a value statement and a cultural competence guide from which to launche specific techniques. The elements are defined below:
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Rapport- Connect on a social level, seek the patient's point of view, consciously attempt to suspend judgment, and recognize and avoid making assumptions
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Empathy- Remember that the patient has come to you for help, seek out and understand the patient's rationale for his or her behaviors or illness, verbally acknowledge and legitimize the patient's feelings
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Support- Ask about and try to understand barriers to care and compliance, help the patient overcome barriers, involve family members if appropriate and reassure the patient you are and will be available to help.
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Partnership- Be flexible with regard to issues of control, negotiate roles when necessary, and stress that you will be working together to address medical problems
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Explanations- Check often for understanding and use verbal clarification techniques.
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Cultural Competence- Respect the patient’s and his or her culture and beliefs, understand that the patient's view of you may be identified by ethnic or cultural stereotypes, be aware of your own biases and preconceptions, know your limitations in addressing medical issues across cultures, understand your personal style and recognize when it may not be working with a given patient
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Trust- Take the necessary time and consciously work to establish trust. Self–disclosure may be an issue for some patients who are not accustomed to Western medical approaches. Take the necessary time and consciously work to establish trust.
SBAR
This acronym represents Situation, Background, Assessment, and Recommendation. This technique can be used to facilitate prompt and concise communication among medical, nursing, social work, and other staff generally after each has interacted with the patient. Use of the SBAR guide should lead to communication that puts all care staff on the same page.
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Situation: What is the situation? What is happening at the present time? What is the acute change? Explain in the fewest words, exactly what the situation is.
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Background: What is the background information? What are the vital signs and pertinent history? Explain how the situation arose. What were the circumstances leading up to this situation?
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Assessment: What is your assessment of the problem? What do you think the problem is?
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Recommendation: What should we do to correct the problem/address the situation? What action/response do you propose?
AIDET
This acronym means: Acknowledge, Introduce, Duration, Explanation, and Thanking the Patient. AIDET is a framework for health care staff to communicate with patients and their families as well as with each other.
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Acknowledge- Greet people with a smile and use their names if you know them. Attitude is everything. Create a lasting impression.
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Introduce- Introduce yourself to others politely. Tell them who you are and how you are going to help them. Escort people to where they need to go rather than pointing or giving directions.
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Duration- Keep in touch to ease waiting times. Let others patients and their families know if there is a delay and how long it will be.
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Explanation- Advise others what you are doing, how procedures work and whom to contact if they need assistance. Communicate any steps they may need to take. Make words work. Talk, listen and learn. Make time to help. Ask, "Is there anything else I can do for you?"
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Thank you- Thank somebody. Foster an attitude of gratitude. Thank people for their patronage, help or assistance.
Here is a brief example of AIDET in action.
Smith's 5-Step Patient-Centered Interviewing
There are many strategies for a more patient-centered approach. One in particular is Smith's 5-Step Patient-Centered Interviewing, a technique of PPC with a focus on conversing in a caring, communicative fashion, and engaging in shared decision making with patients. It is similar to motivational interviewing and OARS (open-ended questions, affirmations, reflective listening, and summarizing), but the focus is on diagnosis and symptom report in the situation.
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Step 1: Set the stage for the interview (30-60 seconds)
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Welcome the patient
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Use the patient's name
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Introduce yourself and identify specific roles
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Ensure patient readiness and privacy
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Remove barriers to communication (sit down)
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Ensure comfort and put the patient at ease
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Step 2: Elicit chief concern and set an agenda (1-2 minutes)
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Indicate time available
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Forecast what you would like to have happen in the future
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Obtain a list of all issues the patient wants to discuss
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Summarize and finalize the agenda
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Step 3: Begin the interview with non-focusing skills that help the patient to express themselves (30-60 seconds)
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Start with open-ended request/question
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Use non-focusing open-ended skills (attentive listening)
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Obtain additional data from nonverbal sources
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Step 4: Use focusing skills to learn 3 things: Symptom Story, Personal Context, and Emotional Context (3-10 minutes)
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Elicit symptom story, i.e., the description of the illness in the patient's words
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Elicit personal context
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Elicit emotional context
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Expand the story
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Step 5: Transition to middle of the interview (clinician-centered phase) (30-60 seconds)
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Brief summary
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Check accuracy
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Indicate that both content and style of inquiry will change if the patient is ready
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Teach-Back
Teach-Back is a research-based health literacy intervention that promotes adherence, quality, and patient safety. This may be the single most important model!
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Ask the patients to explain their understanding of the treatment recommendations (and follow up as needed) using their own words.
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Use non-shaming, open-ended questions.
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Avoid asking questions that can be answered with a simple yes or no.
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Remember that the responsibility to explain clearly is on the provider.
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If the patient is not able to teach back correctly, explain again and re-check.
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Use reader-friendly print materials and/or electronic communication to support learning.
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Document use of and patient response to teach-back.
View this example of Teach-Back.
Research Activity 2
Find one example of poor communication between a patient and provider (TV, Movie, video, etc.). Describe which of the above models may be applied to improve the communication in the situation, and why.
Part Three: Patient-Provider and Other Face-to-Face Channels as Communication Strategies in Public Health
Both clinical and public health professionals often find themselves working with individuals and communities of people facing economic, educational and other social disadvantages. In our highly (and increasingly) diverse society, we also often are communicating with people from other cultural and linguistic backgrounds. So, it is important to be recognizing the needs and barriers that may be present in the populations you work with. It is also important to be strategizing how to best communicate health related topics with these barriers being present. For these reasons, recognize that we may be working through the lenses of our own biases and lack of knowledge, and how these barriers affect the understanding of health information. The above tools may help improve patient-provider communication; however, like any skill, good communication is best learned through lots of practice and continual feedback: from mentors, peers, and the patients themselves.
USEFUL REFERENCES FOR YOUR WORK: For an excellent review of the research in effective patient-provider communication, see Beck, Daughtridge and Sloane (2002): “Physician-Patient Communication in the Primary Care Office: A Systematic Review” http://www.jabfm.org/content/15/1/25.full.pdf+html.
For the specific models of communication referenced above:
SBAR- K. Haig, S. Sutton, J. Whittington. SBAR: A shared mental model for improving communication between clinicians
Joint Commission Journal on Quality and Patient Safety, 32 (2006), pp. 167-175 http://doi.org/10.1016/S1553-7250(06)32022-3
AIDET- Effective patient–physician communication. Committee Opinion No. 587. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:389–93
RESPECT- Effective patient–physician communication. Committee Opinion No. 587. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:389–93
5-step Patient Centered Interviewing - Effective patient- physician communication. Committee Opinion No. 587. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:389–93
& Fortin AH 6th, Dwamena FC, Frankel RM, Smith RC. Smith’s Patient Centered Interviewing: An Evidence-based Method. 3rd ed. New York: McGraw Hill, 2012.
Teach-back- "10 Elements of Competence for Using Teach-Back Effectively" (2017). http://www.teachbacktraining.org/ & Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163:83–90.
American Speeh-Language-Hearing Association. (2017) Augmentative and Alternative Communication. http://www.asha.org/NJC/AAC/
"10 Elements of Competence for Using Teach-Back Effectively" (2017). http://www.teachbacktraining.org/
Effective patient–physician communication. Committee Opinion No. 587. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:389–93
Fortin AH 6th, Dwamena FC, Frankel RM, Smith RC. Smith’s Patient Centered Interviewing: An Evidence-based Method. 3rd ed. New York: McGraw Hill, 2012.
K. Haig, S. Sutton, J. Whittington. SBAR: A shared mental model for improving communication between clinicians
Joint Commission Journal on Quality and Patient Safety, 32 (2006), pp. 167-175 http://doi.org/10.1016/S1553-7250(06)32022-3
Palmer, N. R. A., Kent, E. E., Forsythe, L. P., Arora, N. K., Rowland, J. H., Aziz, N. M., … Weaver, K. E. (2014). Racial and Ethnic Disparities in Patient-Provider Communication, Quality-of-Care Ratings, and Patient Activation Among Long-Term Cancer Survivors. Journal of Clinical Oncology, 32(36), 4087–4094. http://doi.org/10.1200/JCO.2014.55.5060
Patak, L., Wilson-Stronks, A., Costello, J., Kleinpell, R. M., Henneman, E. A., Person, C., & Happ, M. B. (2009). Improving Patient-Provider Communication: A Call to Action. The Journal of Nursing Administration, 39(9), 372–376. http://doi.org/10.1097/NNA.0b013e3181b414ca
Patient Provider Communication. (2015). Communication is the Joint Establishment of Meaning. http://www.patientprovidercommunication.org/
Schillinger D, Piette J, Grumbach K, et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163:83–90.