Good communication with patients (10 principles)

Good communication with patients (10 principles)

Here are CKDEx’s 10 principles of good communication with patients:

1. Start well – introduce yourself properly
2. Active listening – gains trust
3. Mixture of open and closed questions
4. Use the right tone
5. Think about the patient’s perspective
6. Be aware of bias
7. Communicate in different ways – diagrams are useful
8. Keep careful records – and share your notes with the patient
9. Summarise throughout – especially at the end
10. End well – make a contract, and write it down. How can they contact you?

In this article we will describe how to achieve good communication with patients – and go through the 10 principles. Even though this article is largely written for doctors (and medical students), other health professionals and the public may benefit from it too. Here goes.

Why is good communication between a patient and doctor important?

The history (i.e. asking the patient questions) and communication in general, is very, very important as a doctor.”

This is for 2 reasons:

1. It is the key to the diagnosis. 90% if the diagnosis is in the history.
2. If you communicate poorly, you may get the diagnosis wrong (ie. make mistakes and harm the patient) – and/or may upset the patient, leading to complaints which affect your professional reputation.
   Note. These have medicolegal consequences, with 30% due to poor communication.

So. Let’s describe good communication with patients (10 principles)

1. Start well – introduce yourself properly

The start of an assessment is very (very) important for a doctor. Why? Three reasons:

1. It often leads to the diagnosis
2. It sets the tone for the whole assessment; and along with the end of the assessment, it is where trust is gained. Without that little is possible
3. It leads to key information – age, biological age etc

We need to have all of our antennae up, and use every sense – our eyes, ears, nose and ‘sixth sense’.

‘Observation is 90% of medicine’

.. is a phrase taught to one of CKDEx’s co-founders at medical school by a wise GP/Professor of Anatomy. It is still true today. Observation is not just looking, its using all possible methods of communication.

Make sure your mobile is on silent and out of site. Look carefully at the patient as they enter a room. How they look and walk. Are they in pain? Happy/sad? What newspaper are they carrying? Next say ..

To patient. “Thankyou for coming to see me”
“You are Mr/Mrs X, is that right” then “and you are 89 years old, is that right?”
You. “I am Dr Smith/Patel and I am a family doctor, hip surgeon” etc.

Their age is key too, as different diseases are more or less common at different ages.

A handshake is important. It’s partly a greeting but also part of the examination. Some diagnoses can be made by the handshake and subsequently looking at the hands and nails.

A doctor will observe and note the patient’s appearance as they listen: his/her complexion and clothes; the tilt of the head; the movements of the eyes and mouth; how they walk, sit or stand up; the sound of their breathing.

2. Active listening – gains trust

Then listen very carefully the first words they say. Write them down.

Doctors are good at talking (often about themselves). Learn to listen. Listen completely and attentively. That’s how you build up rapport and trust, and have meaningful discussions about treatment. Don’t just think about your next question. Listen now.

Active listening allows us to tailor the information we give to patients (e.g. at the right ‘level’) and gives us cues for when we need to probe a bit more, and if the patient has understood the question. Often, just being listened to is enough to decrease anxiety and stress.

3. Ask a mixture of open and closed questions

Always start with an open question – patients will often talk about what’s on the top of their mind and when this is addressed, they are able to relax and be receptive to closed questions.

For example
‘What is the problem today?’ or ‘how can I help you?’ are good open starter questions, then
‘When did the problem start?’ (open/closed), then
‘Have you noticed anything else linked to it? .. [pause, listen] .. like SOB?’ (closed/open), then
‘Have you ever been a regular drinker of alcohol? (very closed, leading to a yes/no answer)’.’

4. Use the right tone

Simple and concise language is important without ‘talking down’ to patients. Non-verbal communication is just as important as this conveys a sense of warmth and empathy which allows the patient to open up.

Style is important: friendly (not friends), open, polite (lots of ‘thankyous’ and ‘pleases’), gentle humour. Do not eat or drink or check your mobile in front of them. A bag chucked in the floor looks messy. Are you appropriately dressed with clean nails? Make sure they can see the computer screen that you are using, but it does not get in the way of your eye line.

Throwaway lines – e.g. ‘it could be cancer of course’ or ‘are there other alcoholics in your family?’ – are not helpful.

Oh yes. Doctors ‘don’t do adverbs’. The patient is not an ‘epileptic’, ‘diabetic’ or ‘alcoholic’ .. or a ‘kidney patient’. Are you?! They have epilepsy, diabetes or an alcohol issue, and see Dr X for their kidney problem’.

5. Think about the patient’s perspective

Be aware of things from their angle. It’s not about you. Are they in bad mood because of the hospital parking or that the appointment has been rearranged twice? Were they expecting a young/older doctor? Are you still writing notes on the previous patient (don’t) or focussing fully on them (do). Why are you late? Apologise if you are more than 10 mins late.

The assessment may be quite insignificant in your day, i.e. one of 10 today. But huge for them. They may have been anxious for 2 months beforehand. And their family is also on tenderhooks, and waiting for their post-assessment call later.

Be mindful of what’s going on in their life. Maybe they’ve had a bereavement recently; or are caring for someone with dementia at home, who they are worried about. Your holistic assessment of the patient will affect how much they will like you. They need to, as that is part of trust.

Use every method of communication available

6. Be aware of bias

‘The nun is as likely to have syphilis as the prostitute (or doctor!)’ is an old mantra but the principle is still true today.

Never judge the patient. It is not your role.

We must reflect on our biases, acknowledge them and ensure we take steps to minimise them. Your bias – and you have them, we all do – affect how you care and communicate with the patient. If you can minimise bias, patients don’t feel judged and are comfortable sharing deeply personal and possibly embarrassing issues.

7. Communicate in different ways

Patients are different. There is a wide range of intellect, cultural norms, language skill, experience, memory and understanding. So you need more than one tape.

Non-verbal communication is important as well. For example, look at the patients clothing, mood, demeanour, body language, expression, and body positioning. Everything. What is that trying to tell you? Be a detective.

8. Keep careful records – and share your notes with the patient

Accurate documentation of assessments helps share information with other healthcare teams that may need to know; and patients do not have to repeat their story over and over again.

Send copies of all medical letters to patients after a consultation. It helps them to share it with friends and family that aren’t there, and will remind them what you want them to do, and the follow-up arrangement.

Make a note in your diary to chase any crucial tests (e.g kidney function in CKD), especially those that will have a significant effect on the treatment plan (a key CT or biopsy).

9. Summarise throughout – especially at the end

Summarise what the patient is saying, not just at the end of the consultation but all the way through. Asking the patient if you’ve correctly understood the key points of their story shows that you are listening and care that you’ve got it right. This leads to trusts as well.

For example, you might say, after the History of Present Complaint (HPC), “so am I right in saying the leg swelling came on three days ago, 2 days after a long flight, and is getting worse?”

10. Finish well – make a contract, and write it down

This is as important as the start. It will determine what the patient will remember about the assessment; and, importantly, what they think you want them to do, and what you will do for them. This interaction – which should be in the form of a contract – will determine the efficacy of the treatment.

Keep shared decision making in mind. However good their intentions, doctors often revert to saying ‘I think you need this’ or ‘this is my plan’, because they think it works and is quicker – but often it doesn’t work. They need options, even if they are your options!

So. At the end of first assessment, give them a hand written note for them and their GP. It should in the form of a contract, with the following information:

1. What is the diagnosis. Diagrams on the back are good
2. What you want them to do
3. What you are going to do for them
4. Clear follow up plan
5. Your name (in CAPITALS, clearly written), and how to contact you if they have any problems.

Note. Follow up assessments often need a note too.

Some other stuff

A couple of other tips re the end of the assessment

Key points – need to be repeated twice (e.g. “remember to stop the Losartan”). This means they are much more likely to be remembered.

Check understanding – if you think they have not understood you, you can ask them to state what they think is the diagnosis and plan.

Get help from colleagues
Using a multidisciplinary approach can be a good way of overcoming communication barriers. So after a consultation, give them the contact details of a nurse practitioner or other health professional (if you have one) in your team; and say they can also help to answer their questions. It gives them an option of having someone else to talk to.

Be curious
Maintain a sense of curiosity about your patient. Ask yourself: ‘What’s going on with this person? Why are they saying that in this way? Why did they come today, not tomorrow? What is their mood, and why?

Involve friends and family
Encourage patients to have their friends and family with them. Three brains are better than two. When alone and under stress, some people find it hard to remember all that has been said. Family or friends can help them to reflect on the agreed plan and explore the options.

‘Poor historian’
The poor historian is you. There is no such thing as a poor historian. The patient is the witness and you are the historian. If you obtain a ‘poor history’ it is your fault. Did you listen carefully enough? Make good notes? No? Start again.

Summary

We have described good communication with patients (10 principles). The start, end and tone are very important. Trust is vital. We hope they will help make your assessments more effective. If you communicate well, it is good for you as well as the patient. There will be less complaints and you will make less mistakes.

Other resources

Here are other related articles.
How doctors think
What is a diagnosis
Building trust with a patient.

The video from Nottingham University at the top of this page shows good communication skills.