The words "First, do no harm" form the core of every doctor's approach to medicine. The first step to doing no harm, though, is ensuring that both doctor and patient are on the same page regarding a patient's health. Both must understand the nature of an illness, the treatment options, the goals of care and how they fit with both the doctor's and the patient's values and beliefs before care is provided.
Reaching that point requires a close relationship between doctor and patient. However, the communication on which such relationships are founded is all too often lacking, creating obstacles to effective care, increasing health care costs and even causing patients harm.
Pediatric Dose sat down with Dennis Rosen, MD, a Boston Children's Hospital pulmonologist and author of “Vital Communications,” a recent book about communication between doctors and patients, to talk about how the doctor-patient relationship has changed and how to bring effective communication back as a priority.
Pediatric Dose: In what ways does communication between patients and doctors impact care?
Dennis Rosen: Good communication between doctors and patients is the foundation of their relationship and is critical to good medical care. Good communication between doctors and patients leads to better overall health outcomes, fewer hospitalizations, lower health care expenses, greater patient satisfaction, fewer malpractice suits and greater physician job satisfaction.
With all of that said, my sense is that over the last ten years the value that our health care system places on the physician-patient relationship and the communication which defines it has markedly declined.
PD: Why do you think that is?
DR: I believe there are many reasons for this, including pressure to reduce health care costs, and the pervasive and intrusive regulations that doctors are obliged to meet during the time they spend with their patients. Both have changed how doctors and patients interact with each other in ways that have undermined the quality of their communication.
For example: The 2009 HITECH Act mandated certain requirements governing the meaningful use of electronic medical records. Without question, having up-to-date medication, problem and allergy lists readily accessible from within the electronic medical record is very useful for both physicians and patients. However, many of the other regulations are of more questionable benefit, especially as they take away from the finite time available to physicians to better understand what ails their patients and appropriately treat them.
These cost and regulatory burdens, along with pressure to see more patients in the same amount of time—or less—risk sacrificing medium- and long-term health outcomes for some short-term savings.
I also think that our health care system prioritizes cure—identifying a problem and curing it—over care—which needs to address both the objective component of disease and the subjective experience of illness. Illness relates to how the patient experiences her disease process, how she understands it and how she anticipates its progression or resolution. Without considering and addressing all of these, our ability to provide comprehensive care to our patients is necessarily compromised, and the care itself incomplete.
PD: How else does the amount of time available during visits factor in?
DR: I'll give you an example. Researchers in California observed almost 400 interactions between primary care physicians in one practice group and their patients. The median amount of time each physician spent with each patient was 15½ minutes, and during each visit, an average of six problems was addressed. They had slightly more than five minutes to discuss the main problem and then about one minute for each of the other problems. Obviously, that's an impossibly short amount of time to properly address any of them.
As a physician, it is clear to me that if you don't have time to really understand what the problem is, and verify that the patient understands the treatment plan you're proposing, there exists great potential for confusion and misunderstanding. This can easily result in harmful and even lethal medication errors.
PD: But there's more than addressing problems involved, right? I would think a doctor also has to understand a patient's or family's cultural background and experiences.
DR: Absolutely. People come to the doctor because they seek help to maintain or restore their health, but they expect to receive it in a way that is compatible with how they understand the world—including processes of disease and how it should be treated.
Sometimes those understandings are fully compatible with biomedical principles. Other times, they exist in parallel, and occasionally they're frankly incompatible. Without identifying and trying to bridge the gaps that exist between the patient’s beliefs and the tenets of biomedicine, there is a much greater likelihood that the treatment will not be adhered to by the patient, whose health will suffer as a result.
It is therefore very important to understand how the patient perceives what is happening with him and how he believes that condition should be treated. At the very least these beliefs can be recognized even if the treatment is ultimately biomedical.
PD: When in a doctor's career does the focus on patient communication begin to break down?
DR: In a perfect world, doctors would start learning how to be good communicators even before medical school. But I think that it is during residency, when they find themselves overwhelmed by the volume of work they need to complete, that they begin to spend more time with their computers than with patients. For example, a recent study in Baltimore found that interns in two large internal medicine residency programs spent an average of 12 percent of their time directly interacting with their patients versus an average of 40 percent of their time in front of computers.
I’m also not sure how well our system encourages the modeling of good communication with patients by more experienced clinicians to trainees. While we want them to become self-sufficient and to take the lead in caring for and interacting with patients, perhaps we need to dedicate more time for more senior physicians to observe and advise interns, residents and fellows on how to improve their communication skills.
PD: How can we resolve this problem?
DR: First, we really need to make sure that doctors and patients have enough time to spend with each other during their visits. A few extra minutes spent with patients to make sure that they're taking their medications properly would go a long way to keeping people healthier and to reducing nonadherence rates and the incidence of medication errors.
Second, we need to better utilize technology to extend the impact of the doctor-patient encounter into other portions of the visit. This could include making tablet-based health history questionnaires available for patients to fill out in the waiting room before the visit begins, and using the same devices to screen patient-specific educational videos both before and after the visit that would amplify and reinforce what is discussed with the physician.
And there are simple things we as physicians can do when talking with a patient to make our communication more effective. For instance, don't type visit notes during a patient's visit. Maintain eye contact. Encourage patients to take notes during their visits and review these with them before they leave. Use visual aids or decision-making aids to help make sure patients make informed decisions. There is also evidence that communication workshops for doctors can have long-lasting and positive effects.
PD: But for those solutions to work, we need to have the time to make them work.
DR: That's right. We spend over $2.5 trillion a year and the highest proportion of GDP in the world on health care, and yet our infant mortality rate, for example, ranks 27th among OECD countries. What we’re doing right now simply isn’t good enough. By broadening the current focus on so-called efficiency to include strengthening the patient-doctor relationship, we will facilitate good and comprehensive care in ways that will benefit patients, physicians and society as a whole.