Course: Communication with Patients

Professor: Maria Ida Gobbini

Date: 06/10/2021
Topics: Introduction to Doctor-patient communication
Sbobinators: Caterina Denicolo’, Elad Fayel
Supervisor:

The exam will be a multiple-choice quiz. Within one month, the professors will publish the exam dates. For the exam, the material
covered in class should be reviewed. In Virtuale, there is a bibliography for students who wish to go in depth about certain topics.

Doctor-patient communication
Introduction
The purpose of this class is not to give an easy recipe on how to deal with patients in detail but conveying a
type of communication that can be used as a scaffold for doctor-patient interaction, according to one’s
personal style.
“Medicine is not a factory. It’s art and science”. Doctors are not mechanics, fixing broken machines: they
are much more. The process of healing for patients is not just being prescribed drugs but is intrinsic to the
relationship with the physician.
Today, the concept of placebo effect, which was introduced three years ago, will be further explained.
There is recent research comparing the placebo effect to the effect of prescribing drugs: results are quite
ambiguous. Also, recent papers are investigating what are the biochemical mechanisms that the placebo
exerts on the brain.

Overview of the course

- Patient-centered communication. This approach is becoming more and more common and focuses
on the importance of listening in doctor-patient communication.
- Implicit bias in healthcare. This is an extremely important topic, of which not many are aware.
According to the American Autoimmune Related Disease Association, 45% of patients with an
autoimmune disease are labelled as ‘chronic complainers’ in the early stages of their disease,
delaying the diagnosis of the disease. Another condition that is often dismissed is endometriosis.
Endometriosis is a disease of the reproductive system; it affects 1 every 10 women. The reasons
behind this disease are still unknown. The inner layer of the uterus, an epithelium, covers other
body parts, such as the ovaries, or the peritoneum, causing chronic pain. It may take up to 7 years
to receive a diagnosis, as the main symptom is pain: if a man reports pain, doctors pay attention to
him, but a woman is often dismissed as mentally ill. A student suggested that mood swings, related
to hormonal changes, cause a further delay in diagnosis. Besides gender, race should also be
considered. In California, the mortality rate among pregnant black women at delivery was higher.
There are different levels of bias, which must be taken into consideration when approaching the
patient.
- Emotion and Empathy. The physiology of emotions will be studied, and the reasons why emotions
exist, and where they originate. Studying the physiology of a certain disease, such as hypertension,
is as important as studying the physiology of emotions. Empathy is the core of communication with
patients. It’s important to know the level of involvement a doctor should have with the patient:
while always keeping an emotional distance from the suffering of the patient, they should be able
to understand what the patient is experiencing.
- Burnout syndrome, which affects in the USA at least 43% of people involved in health care.
- Mechanisms of pain perception will be reviewed, starting from the study of physiology, as to
understand where the placebo and nocebo effects originate from.
Doctor-patient relationship
Since doctors are professionals, they must have a degree and a license. Moreover, they should abide by the
principles of beneficence and non-maleficence.

There are different types of doctors.

- Doctors who believe the physician has the knowledge and therefore should not be questioned.
They believe the patient is not supposed to ask any questions.
- Doctors who just give patients alternatives and tell them to choose. The ethical principle of
autonomy implies that the doctor explains in detail every alternative.
- Doctors who spend time assisting the patient in making a decision.

There are different types of patients.

- ‘Ignorant’ patients, who don’t know what cough or cancer is; they have absolute trust in any
physician.
- ‘Informed’ patients, who are aware of diseases and their rights. Patients question the physician
more and more and want to know why a certain drug was prescribed. There are also patients
questioning doctors based on what they read on the internet. In the past two decades, society has
changed, and patients have transitioned to a more enlightened attitude. At the same time, there is
another transition imported from the USA: doctors are becoming afraid of being sued by patients,
and this affects the way physicians approach patients. The fear of being sued leads physicians to
follow a ‘bureaucratic’ approach, following strict rules.

Personal anecdote: During my second pregnancy, I was over 40 years old. I was in the USA, and I had to
travel back to Italy: it was the 9 th week of pregnancy, and the obstetrician suggested I do a sonogram to
make sure everything was fine. Usually, sonograms are performed from the 11 th to the 13th week. The
radiologist saw an abnormality behind the neck, which is a sign of malformation. He gave me the protocol
on how to investigate this supposed-to-be malformation, starting from a chorionic villus sampling, which is
an invasive procedure and may result in a spontaneous miscarriage. Being in a big hospital in the USA, I
thought I was receiving the best possible care in the world. Before performing the chorionic villus sampling,
I spoke to a geneticist. He told me that since it was a severe malformation, I had to go back to Italy and
perform an abortion there (a very bad way of approaching the patient, this is the worst experience in the
medical field in my life).
I went back to Italy, to the obstetrician that followed my first pregnancy. He said that you can’t draw any
conclusion from a sonogram performed at the 9thweek. I repeated the exam in the 12th week, and everything
looked normal. I asked him to perform an amniocentesis, and he strongly discouraged me to do so because
it was an invasive procedure. These two examples represent two very different ways of approaching the
patient: the fear of being sued leads physicians to suggest invasive procedures. The obstetrician in Italy, on
the other hand, evaluated the risk for me, not for him: my daughter is now 10 years old, and she is perfectly
fine.

Interactions
There is a discrepancy between the time a doctor needs to answer all the doubts of a patient and fulfil the
patient’s expectations, and the short time allowed for each visit. Often, lawsuits are motivated by
miscommunication.
Doctor-patient interactions have an impact on the healing process.
Doctors can come across as compassionate, kind, and caring or can cause mistrust, confusion, and anger.
Interactions determine compliance, outcome, and satisfaction.

Patient centred interviewing

This type of approach improves trust, the experience, and the outcome. The experience is improved not
only for the patient but also for the doctor.
ALERT: this acronym gives an overview of this type of interview.
A: acknowledgment of the patient, and of yourself as a physician. You must introduce yourself, and say why
you are there.
L: Listen, you must spend time listening to the patient. With experience, you will learn how to listen to the
patient without spending hours doing it. It has been proven that the most important information can be
collected in the first two minutes of uninterrupted talking.
E: Explain. Patients require an explanation for example the reason why a certain test was chosen, or a drug
prescribed.
R: Review, otherwise the patient could make mistakes. You must assess the understanding of the patient.
T: Thanking the patient for the opportunity to serve. The profession of the physician serves others.

Patient-centered communication
Effective doctor-patient communication is fundamental for patient compliance, especially in chronic
situations.
- An aggressive behaviour is not effective.
- Being insecure and passive is not effective, as no sense of authority or reassurance is conveyed to
the patient.
- Being assertive might be the most effective approach. The doctor-patient communication is
asymmetrical: the doctor is the leader of this communication.

The Placebo effect

New findings about the placebo effect may influence how doctors are trained to interact with patients.
A placebo is a substance or treatment which is designed to have no therapeutic value. Common placebos
include inert tablets (like sugar pills), inert injections (like saline), sham surgery, and other procedures.
Patients’ expectations on placebo, however, could have dramatic outcomes: they might report
improvements.

Socially transmitted placebo effect

In this study, published three years ago, it was found that the physicians’ expectations reflected on the
patient.
Patients had a camera strapped in the forehead, so that the face of the physician was recorded during the
experiment. The experiment consisted in inflicting in the laboratory a painful, but not injurious, heat
stimulation on the forearm. The treatment consisted in administering either Thermedol, a pain relief
ointment, or petroleum jelly. The physicians thought that this was a single-blind experiment, where
patients did not know whether they were receiving an effective treatment or a placebo. In reality, all
patients were treated with petroleum jelly.
A trained and sophisticated AI algorithm recognized pain on the doctors’ faces believing to treat patients
with petroleum jelly, and not with Thermedol.
A less pained expression by the doctor believing to treat patients with Thermedol correlated significantly
with the pain relief patients experienced.
So, facial expressions can influence how the patients experience pain.

Doctor-patient communication
Attitude of the physician
- Authenticity. Doctors should avoid having stereotyped expressions, such as a fake smile. They
should be in contact with one’s own thoughts, feelings, and emotions. This is also important for
diagnostic purposes. For example, if a doctor lets the patient speak uninterrupted, and then feels
deeply sad, it could be a sign of the patient’s depression.
- Keep an open mind, independently from what the patient does, thinks, or feels, independently of
gender or race. Doctors often make inferences about the patient’s look and personality.
- Empathy. Doctors must learn how to experience empathy without feeling overwhelmed, or it could
expose them to Burnout syndrome.
To help the patient to:
- Understand the situation
- Manage the problem
- Make sure their choices are realised

What is patient-centred care?

- The approach of health services which is tailored to patients’ needs and provided in partnership
with them rather than given simply to them, something that becomes more and more common in
the health care practice
- Care where people are respected, informed, engaged, supported, and treated with dignity and
compassion, and fulfils the expectations of the physical therapist as well
Why does it matter?

- Improves the trust, since there is better communication with the patient, and also the experience
and outcomes people have from care
- Increases the confidence and satisfaction of health professionals
- Improves the quality and efficiency of the health system, since the increase in the trust will reduce
the risk in “doctor shopping”, a phenomenon which happens when patient switch doctors until
they find someone who they are satisfied by, this increase the number of tests being done and the
cost for the health system

Interviewing principals of patient-centred care:

- Patients often do not seek health care only because of a symptom

- The personal context of the symptom
o For example, back pain might be very limiting for some patients that work in physical
activities
- Symptom or its context creates an emotion
- Patients usually bring more than one problem
- The first issue the patient mentions is often not the only nor the most important
o It’s important to explore more broadly the different symptoms the patient might have and
ask for related issues and the whole picture even before launching our questions since it
might save time later
- Allowing a patient to tell their own symptom’s story is therapeutic
o Diagnostically helpful, but also since the patient's storytelling by their own words can have
a therapeutic effect by itself (e.g. telling about our day to a friend)
- An important concept is the fact that it is not enough just to listen and understand the patient’s
story during the interview, but it’s necessary to have an empathic conversation and show the
patient our attention

Better intermediate health outcomes

- Improves patient’s recall
- Improve medication adherence and compliance
o Listening better to the patient’s habits, symptoms, and lifestyle can have a better effect on
the treatment.
o In addition, there is a real physical improvement for the patient which is not psychological
and it’s based on the relationship with the physician
- Fewer tests and referrals – reduces the cost for the health system and improves the quality of the
care
Better social health outcomes
- Less ‘doctor shopping’
- Lower risks of malpractice lawsuits
- Greater patient satisfaction
- Greater physician satisfaction is based on the sense of connection with the patient

A standardised approach to interview the patient, by Dr Robert Smith

This standardised approach is an integrated patient-centred and doctor-centred interviewing. We are going
to see a scaffold of a suggested physician-patient approach which is going to be shaped by ourselves once
we become doctors.

The standardisation of the approach:

Beginning:
- Greeting
- Set the agenda – how are we going to spend the time together, the patient is going to know
what is going to happen during the examination
- Patient-centred skills (HPI) – allow the patient to talk and to listen to their symptoms and
experience uninterrupted with open-ended questions
Middle:
- Doctor-centred skills (PMH, Meds) – asking a closed-ended question that helps to investigate
the symptoms based on the story of the patient
- Physical exam
End:
- Education – making sure the patient understood what has happened during the examination

Patient-centred interviewing

The limited time the physician has means that the beginning of the interviewing should stay quite short,
around 1-2 minutes for each part (each bullet), however, it is still useful to allow to guide the questions
being asked later on during the doctor-centred interview, therefore improving the quality of the visit.

The interview procedure

It is important to install a sense of comfort and support during the patients’ interview, this can be achieved
by distinct stages in the interaction with the patient. The following points describe the flow:

1. Opening or introductory phase:

a. Welcoming the patient, introducing ourselves, and identifying our specific role
b. Ensuring the patient’s readiness and privacy
c. Remove barrier to communications
i. Like a screen between the two
d. Ensure comfort and put the patient at ease
i. For example, we need to make sure that patients with disabilities can feel
comfortable and be able to communicate with us, like making sure that a deaf
patient has a hearing device or a companion.
ii. Another example, we should not stand while talking to a sitting patient, but sit at
the same level next to them
- Question: is there anything that should be done especially for children?
o The same rules apply here, in addition, one parent should stay with the child to help them
feel reassured, as the child is found with a stranger in a new environment

2. Gathering information and going in-depth:

a. Assessing the chief concern (ask the patient if there are other reasons of concern!!) and set
the agenda
i. As soon as the patient finished explaining his complaint about their main concern,
it’s important to ask about other concerns the patient has before asking about the
symptoms of the main issue, and then to set the agenda (telling the patient what
the examination is going to be like)
b. Obtain a list of all the issues the patient wants to discuss
c. Beginning with non-focusing questions:
i. Allow the patient to talk uninterrupted: a key technique in facilitating the
interview.
1. It’s important to avoid interfering in any form
ii. Assess the patient’s understanding
iii. Assume questions
iv. Assure understanding – making sure that everything that was talked about is
understood
d. The physician summarises the info gathered from the patient (rephrase what the patient
said after they finish their story)
i. We might want to use some of the words the patient uses – echoing, if the patient
says “Pain in the head” we should use the same term and then ask “tell me more
about the pain in the head”, this method can help to investigate the situation
better.
e. Focus on the symptom story to investigate further the history of present illness (HPI), e.g.
“What else can you tell me about what's been going on?”
f. If the physician chooses to do so, they can ask about the personal and emotional context
i. Here it’s important to pay attention to the non-verbal communication aspects, the
emotion in the face, talking without energy, not looking at the physician’s face
g. Focusing skills – open-ended skills to get the patient to speak their own words in the way
that they want to speak
i. While being silent when we hear the patient’s story, we should make sure that we
show interest in the conversation and communicate by nodding our head or
making approval sounds
h. Relationship building – techniques that include emotion seeking and empathy skills which
help to build a better relationship between the physician and the patient
i. While trying to understand the patient’s emotions in the right context, we also
need to express our understanding of the patient’s emotions in an affective
systematic way, and not just keep it in our minds
ii. Emotion seeking skills – can be direct and indirect
1. Direct – asking how the symptoms the patient has makes them feel,
another example can be saying: “I can see how hard it is for you, how does
it make you feel”
2. Indirect – asking about the impact of the pain in the patient’s life, asking
for example: “why did you come to see me now after experiencing the pain
for a month”
 iii. Empathising skills – NURS
1. Name – name the emotion the patient is expressing
2. Understanding – be able to show we understand the patient’s feelings and
where they are coming from
3. Respect – acknowledging the patient and making sure the patient feels
respected
4. Support – supporting the patient

i. Open-ended beginning question – our main way to get information from the patient
j. Non-focusing open-ended skills
k. Obtain additional data from non-verbal sources

3. Summary and closure or the concluding phase

a. (wasn’t discussed during that lesson)

During the interaction with the patient, the following should be kept in mind:

● Ask questions that might facilitate expressing why the patient is worried, e.g. How can I help you?
What is your major concern?
● Listen to the issues/doubts/worries expressed by the patient without simplifying them, minimising
them, or offering immediate solutions
o When the patient talks freely there might be moments which they talk about their
emotion, worries, and doubts, the act of listening can be reassuring and very important for
the patient
● A physician can be reassuring without being paternalistic or contradicting what the patient is saying
● Answer explicit requests

In the following lesson, we will talk about verbal and non-verbal communication.