After the birth of her second child, Claudia Brown, a marketing specialist in Chicago, was feeling down. Worried she might have postpartum depression, she called her primary-care physician. The doctor was concerned about her symptoms but unavailable to see her that day, so she urged Brown to see her partner, a man she'd never met. At the appointment, Brown explained how she'd been feeling. The doctor was dismissive, telling her she was just tired and quickly sending her on her way.
"It took a lot to admit to myself that I might have postpartum depression, and I left that appointment feeling even worse," Brown says. Confident and assertive by nature, she's normally quite comfortable talking about medical issues and asking follow-up questions of her physicians. "But if a doctor sets a negative tone, I just shut down," she says. "I gave up, and got nothing out of the visit."
Unfortunately, Brown's experience may not be unusual. Dominick Frosch, PhD, an associate investigator at the Palo Alto Medical Foundation's Research Institute and associate professor at the University of California, Los Angeles, and colleagues recently held focus groups in San Francisco to explore how patients discuss health-care issues with their physicians (Health Affairs, 2012). They found that even well-educated patients feel intimidated in the physician's office.
"In the context of a medical consultation, people feel uniquely vulnerable," Frosch says. "Asserting their views might require disagreeing. Patients fear that will lead to negative consequences that might impact their care in the future."
The result? Patients often hold back from asking questions or sharing opinions, and end up less involved than they could be in making their own medical decisions.
The good news is that professionals across disciplines are working to improve patient-physician dialogue. In many cases, today's well-informed patients are driving that change. "Nowadays, anyone can go to the Internet and plug in their symptoms," says Frosch. "The trend is toward patients wanting more involvement."
For that to happen, patients and physicians must communicate well. It will be a challenge, Frosch says. "We've got quite a long way to go to get to an ideal partnership between the health-care team and the patient."
Psychologists, with their expertise in behavior change and communication, are poised to be just the people to help. The field's efforts to improve patient communication are ramping up in response to the push for integrated care, driven by market forces as well as the Patient Protection and Affordable Care Act.
Psychologists can work with patients to help them prepare for medical appointments about which they might be anxious or concerned. They might also help physicians understand cognitive deficits or other difficulties affecting individual patients. Perhaps a patient has trouble asking questions due to anxiety, or finds it challenging to retain information that's presented orally. Psychologists can help physicians adapt their communication strategies to address such limitations.
"There are things we can do to help our health-care colleagues understand the specific needs of patients so they can tailor their way of communicating," says Lynn Bufka, PhD, assistant executive director of practice research and policy at APA.
As members of integrated health-care teams, Bufka says, "Psychologists have a lot to offer in terms of [addressing] behaviors that impact health care."
The ticking clock
Sharing information is a critical piece of health care. "There's a lot that happens in medicine that doesn't work if the communication doesn't work," says Evelyn Y. Ho, PhD, an associate professor of communication studies and Asian-American studies at the University of San Francisco. "In so much of medicine, we often don't pay attention to that human interaction — and that's when you get problems."
Effective communication is linked to many positive medical outcomes, research shows. "Good communication is associated with patient adherence to treatment, control of symptoms, control of pain and patient satisfaction," says Kelly Haskard-Zolnierek, PhD, an associate professor of psychology at Texas State University. Informed patients are also more likely to decline elective surgeries and disease screenings that could lead to risks from false positives and unnecessary interventions, adds Frosch.
The benefits of good information flow have not gone unnoticed. "There has been quite a culture change in the last 20 years," says Carma Bylund, PhD, director of the Communication Skills Training and Research Laboratory at Memorial Sloan-Kettering Cancer Center. "Now virtually everyone has training in communication in their medical schools."
But seminars and good intentions only go so far. "Doctors know how important health communication is. Everybody is aware, but it's still difficult to do," says Ho.
Communication can falter for a variety of reasons. Patients who are ill (or afraid they might be ill) may suffer from heightened anxiety, which chips away at their self-confidence. Language barriers can drive a wedge between patients and their doctors. Less obvious structural barriers may also impede the conversation, says Ho. For instance, when patients belong to a health-care system in which they see a different provider every time, they may never develop a comfortable rapport with a single physician.
Then, of course, there's the ticking clock. Physicians are famously, and almost universally, pressed for time. "Ten- to 15-minute appointment slots are an insane system" for helping people, especially those with complex chronic illnesses who need ongoing treatment, says William Polonsky, PhD, founder and president of the Behavioral Diabetes Institute, a nonprofit organization. "No matter how highly skilled you are, it constrains you."
Alas, physicians aren't likely to discover extra hours in their days. Fortunately, research suggests some ways to improve communication even in short interactions with patients. Paul Arnold, MD, at the University of Kansas Medical Center, and colleagues found that when physicians sat at a patient's bedside, the patients perceived the visit as lasting longer than they did when physicians stood, even though the visits lasted the same number of minutes (Patient Education and Counseling, 2012). Simply pulling up a chair can leave a patient feeling more satisfied, leading to better patient compliance and stronger patient-physician relationships.
Another new study by L. Aubree Shay, a doctoral candidate at Virginia Commonwealth University, and colleagues found that patients rate physician communication more positively when the physicians take relatively simple steps, such as inviting patients to express their concerns, or extending the interaction outside of the exam room with a chat or referral exchanged in the hallway or reception area (Patient Education and Counseling, 2012).
Beyond these simple measures, Bylund says, physicians would do well to think about time in new ways. Instead of worrying about the length of an appointment, she encourages physicians to consider the long-term effect of investing in communication from the outset.
"You may save time in the long run by having good communication in the first visit rather than having patients come back multiple times because they feel like they aren't getting what they want," she says.
The biggest gains, though, may come from helping physicians and patients communicate more effectively despite the time constraints. While communications training is increasingly routine for physicians and nurses, there's room to improve that instruction.
"More and more medical schools and residency programs are realizing they need to deal with the communication aspect," says Haskard-Zolnierek. "I think psychologists are great people to do some of that teaching and training."
Several psychologists, including Polonsky, are working toward that goal. With his colleagues at Taking Control of Your Diabetes, a nonprofit organization that hosts one-day conferences for patients across the United States, he brings medical professionals and diabetes patients together for large group discussions. Polonsky begins the programs by asking participants to discuss what annoys them about one another. He finds that diabetes patients often feel as if their physicians don't have their best interests at heart, while their physicians are frustrated that the patients aren't following their advice.
"Early on [in the meetings] they can get pretty angry with each other and say really terrible things" — even going so far as to call one another liars, Polonsky says. "Then they begin to consider what things are like from the other side. What they all come to realize is that their major complaint is the same: I feel like I'm the only one who cares. The session then changes pretty dramatically, and the question becomes, what can we do about that?"
One place to start is helping medical providers understand that patients do care.
"Just like physicians, all patients would prefer to live long and healthy lives. The problem is not that patients need motivation, but that there's something in the way," he says.
Patients with chronic illnesses, such as diabetes or heart disease, are at increased risk of depression, for instance, which can sap their energy for making important lifestyle changes. When communication succeeds, physicians can identify and start to address such hurdles.
"When it comes to promoting behavior change, one of the physician's first jobs should be to think of himself or herself as an obstacle remover," Polonsky says.
Often, physicians are eager to find ways to improve communication with their patients, says Susan McDaniel, PhD, a professor of psychiatry and family medicine at the University of Rochester Medical Center. She has spent most of her career teaching communication skills to primary-care physicians. As health-care reform unfolds, she says, there are increasing opportunities to expand that same teaching to all kinds of physicians.
McDaniel is developing the Patient- and Family-Centered Care Physician Coaching Program. She spends half a day with a physician, observing his or her interactions with patients and providing feedback and suggestions.
Early on, physician leaders and administrators worried that the medical doctors might resent being told what to do. Instead, she's found, "they are amazingly receptive and responsive." The program is so successful that she's now training five more psychologists to shadow and coach the faculty physicians. "I've been surprised by how popular [the program] has been," she says. "I think it meets a need for people who may not be focused on their communication skills, but really do want to be the best they can be."
Of course, physicians are only half of the equation. Haskard-Zolnierek has found that when both patients and physicians are trained in communication, physicians report lower stress and greater satisfaction with the relationship than they do when just one of the pair receives training (Health Psychology, 2008). "Both people are bringing different perspectives and skills and levels of communication. If you only focus on one of the two people, you may be missing an important piece," she says.
Just a few minutes of coaching can encourage patients to ask questions and seek out information. As she imagines it, that training could take any number of forms. Clinics could mail or email pre-visit information to patients, priming them to make a list of topics they hope to discuss during their next visit. Electronic training kiosks in waiting rooms could guide patients through similar steps to prepare for their consultation, she says. "Even if it's not much training, patients become sensitized to the idea of becoming involved," Haskard-Zolnierek says.
Ho has also explored the feasibility and effectiveness of training patients to communicate more effectively with their physicians. In one project, she and her colleagues trained patients to talk with their physicians about their use of complementary and alternative medicine (CAM). Studies show most patients don't tend to bring up their CAM usage at medical appointments — a problem since some alternative therapies could interfere with conventional medicines. Ho and her team conducted a workshop to help patients build four skills: preparing a list of questions before the appointment; being proactive by initiating the CAM conversation; disclosing all CAM use; and asking relevant questions. After the workshop, more than half of patients mentioned their CAM use within the next two physician visits — a positive sign, Ho says. Follow-up surveys also indicated that more than 80 percent of participants demonstrated the "be proactive" skill while meeting with their physicians (Patient Education and Counseling, 2012).
The results are encouraging, she says, but they're just a first step. She's exploring the creation of an online training session to reach more patients. She also hopes to do further research to flesh out what successful physician-patient conversations should look like. In the case of CAM, she points out, good communication is more than simply knowing which herbs a patient takes. It's about fully understanding each patient's health-care preferences and habits.
"The communication is really important, but we really need to think about what you can accomplish from that communication," she says.
Joining the team
To date, most research on health-care communication focuses on a two-person, patient-physician dynamic. But that tight circle is expanding. "There is more and more emphasis on health-care teams," says Haskard-Zolnierek. This team-based approach, commonly known as integrated care or patient-centered care, is gaining popularity across the country. The Patient Protection and Affordable Care Act, for example, includes several initiatives that promote integrated care by encouraging health-care providers — including psychologists — to participate in "health-care homes" as part of health teams.
While promising, the team-based approach is still quite new, says Polonsky. He's just beginning to see such collaborations in diabetes care, where teams may include certified diabetes educators and nutritionists along with physicians and nurses. Bufka adds that successfully integrating psychologists into health-care settings involves providing behavioral care beyond traditional mental health duties. In such cases, for instance, a psychologist may help patients with compliance or help them develop strategies to maintain a healthy weight.
One big advantage of the group approach: Team members can reach out to patients to provide information and answer questions that time-crunched physicians aren't able to. "We're seeing some creative things happening where we can leverage physician time," Polonsky says. "I think psychologists can play a role in that — there are real opportunities there."
After all, Ho adds, "We might have the best medicine in the world — but it won't be successful if the patient doesn't understand it."
Kirsten Weir is a writer in Minneapolis.
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