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What you say vs. what patients hear

Strategies for improving patient communication, compliance, and satisfaction

Dermatology World abstract illustration of tin cans

What you say vs. what patients hear

Strategies for improving patient communication, compliance, and satisfaction

Dermatology World abstract illustration of tin cans

By Emily Margosian, content specialist

The scene is set. Already running behind in the day’s schedule, a dermatologist sees their next patient. However, the patient — being seen for warts — is full of questions. They also have a benign appearing mole, and a toenail has been looking funny. From the physician’s perspective, the day needs to continue moving and the original problem — the wart — is routine. The rest will have to wait for another visit. From the patient’s perspective, the physician is cold, condescending, and dismissive of their concerns. Both patient and physician leave the appointment feeling the other has been unreasonable. How could this situation have been avoided?

“Good communication with patients is obviously a big part of what we do,” says Kanade Shinkai, MD, PhD, professor of clinical dermatology at the University of California San Francisco. “There’s an immense reward that comes from connecting well with patients, but also in this day and age of value-based care, patient satisfaction scores are now tethered to reimbursement. So in addition to making their care more effective, it’s also very important for dermatologists to pay attention for that reason.”

As effective communication between providers and their patients takes on additional significance, dermatologists discuss their own strategies for better seeing eye-to-eye with patients, including:

  • Practicing clinical empathy
  • Joint decision-making
  • Agenda-setting
  • Conscientious phrasing
  • Body language
  • Checking patient comprehension 

Don’t get lost in translation

“I think that getting on the same page with patients is a challenge for many dermatologists, because it’s very hard for us to really understand patient perceptions,” says Neil Prose, MD, professor of pediatrics and dermatology at Duke University Medical Center and affiliate at the Duke Global Health Institute. “We think we know, but we often get it wrong.” When a disconnect occurs between what a physician says and what the patient walks away with, oftentimes compliance, outcomes, and trust all suffer. Bridging this disconnect should be a key goal for all providers, as unfulfilled expectations may impact a patient’s overall level of satisfaction with their care, even more strongly than the technical success of a treatment (Expert Rev Pharmacoecon Outcomes Res. 2012;12(2):149-58).

Practicing clinical empathy is often the first step toward bridging this divide, and has begun gaining increased traction as an essential foundation to building physician-patient trust. More than just good bedside manner, “empathy is a cognitive attribute, not a personality trait,” explained Mohammadreza Hojat, a research professor of psychiatry at Jefferson Medical College, in a 2015 CNN report. “One of the worst things you can do as a provider is to downplay the patient’s concerns,” John Koo, MD, professor of dermatology at the University of California San Francisco, board-certified in psychiatry and dermatology, elaborates. “In psychiatry it’s called ‘empathic failure.’ Empathic failure can occur when the provider may think they’re doing the patient a favor — perhaps by saying, oh you only have a little bit of acne — but the patient takes it totally negatively, like you don’t understand, you have no idea what I’m going through. The provider may mean well, but it’s a great way to create an even bigger problem and drive the patient away.”

patient-comm-quote.pngGood physician-patient communication — or lack thereof — can have legal implications as well. “Most patients are willing to forgive a medical error if they feel they’ve been treated with respect, but when a patient believes their views have been devalued, their perspective ignored, or that they have been abandoned, anger — not injury — drives their decision to sue,” explained a 2015 Medical Liability Monitor article. “The real story here is that when patients are asked about the root cause underlying their decision to litigate, most report it was because of the way the physician made them feel.”

In addition to filing fewer malpractice claims, patients who feel their expectations have been met and they have been treated with respect by their providers are more likely to follow treatment recommendations and remain loyal patients. A physician’s demeanor, phrasing, body posturing, and tone of voice can all have a great impact on their patients — consciously or not. “There’s the world of medicine, and then there’s the lifeworld of the patient,” explains Dr. Prose. “The world of medicine is full of science, techniques, solutions to problems. The lifeworld of the patient is largely composed of worries, anxieties, and financial concerns.” What may be just another appointment, or another box to check in a busy day for a dermatologist, may in fact be a highly emotional moment of crisis for a patient. “The job of the dermatologist is to bridge those worlds by using particular techniques that allow them to work on things together,” says Dr. Prose. “I like to imagine the metaphor of sitting across the table from the patient, and the problem is in the middle of the table. Figuring out what it takes to get on the same side of the table, looking at the problem together, is what this is all about.”

Communication with delusional patients

 For many providers, establishing good patient communication is challenge enough. 

 However, dealing with delusional patients in particular often adds a whole new level of difficulty for many dermatologists, says John Koo, MD, professor of dermatology at the University of California San Francisco, board-certified in psychiatry and dermatology. “There is a huge disconnect as you can imagine. This disconnect usually ends with the patient getting angry, the dermatologist getting angry, the situation turning ugly, and the patient ultimately getting no treatment,” he says. 

However, how can dermatologists engage with patients whose concerns lie outside the realm of reality? “The first disconnect is obviously that there’s a huge gap between the patient’s belief and the dermatologist’s belief,” explains Dr. Koo. “The patient may think that they have parasites or fibers coming out of their skin — that’s the patient’s position. The provider’s position is of course scientific and objective, and they will want to respond ‘that’s impossible.’” The first step to overcoming this seemingly insurmountable difference in perspective is to rethink the underlying priority of the patient, suggests Dr. Koo. “On a surface level, you might think the patient just wants agreement and validation; in reality that’s not the case most of the time. What the patient often wants most is to get better. These people are not having fun; they are having the most miserable time of their life.” Once the provider has minimized the patient’s desire for validation about the perceived cause of their condition, and instead maximized messaging about the assistance they are willing to provide toward alleviating the patient’s suffering, then oftentimes headway can be made. 

In general, Dr. Koo suggests the following steps for physicians engaging with delusional patients to reach an outcome agreeable to both parties: 

Prepare yourself mentally before the visit. “Whenever most dermatologists hear that one of these patients are waiting to see them, they feel a great aversion,” says Dr. Koo. “If you go into the room looking like you’re not interested, then things go downhill very quickly. A lot of times these people feel like they’re getting shooed out of the office, because they are.” 

Project positive body language. “Pretend you’re meeting your favorite Hollywood star. Smile, let your eyes shine, because body language doesn’t cost you any time, and can really help in the long run.” 

Be pragmatic... “I purposely tell the patient that I’m not an entomologist; I’m not a parasitologist; I’m not even an infectious disease specialist, and if they’re mainly interested in the cause, I can’t help them,” says Dr. Koo. 

But empathetic. “I typically connect with the patient by explicitly telling them that I understand their misery, and sometimes that alone can drive the patient to tears because they’ve been dismissed so many times previously by other providers. The provider and patient often don’t know how to connect with each other in this situation, and most of the time the patient goes untreated, or will be given topical steroids or topical antibiotics — which is no use because they really do need antipsychotics.” 

SAY THIS, NOT THAT: NAVIGATING POTENTIAL PATIENT PROBLEMS

While all doctors have their pet peeves when it comes to patients, some stand out among the rest. “When I do seminars with dermatologists, one of the main concerns is the patient who comes in with a list of concerns,” says Dr. Prose. “There may be a big disparity between the things that are the most concerning to the dermatologist — such as a potential melanoma — and the things that may be of more concern to the patient, which may be something as simple as cosmetic treatment for wrinkles, or a toenail fungus, or something else entirely.”

Given that an appointment is a finite amount of time, and that unmet expectations are a major cause of patient dissatisfaction — how can dermatologists align their clinical priorities with those of the patient in a way that fosters a sense of partnership, rather than dictation? Joint decision-making is one solution. This technique typically follows a script in which both patient and provider are given space to express their main aims for the appointment, and then jointly decide which will be addressed that day. “I think there are points in the conversation where joint decision-making becomes critical, typically when a patient is deciding to begin a medication like a biologic, or a systemic medication for a condition like psoriasis or eczema,” says Dr. Prose. “You have to be really sure that everybody’s on the same page before embarking on that treatment. To me, there are some very specific things to say to facilitate that process.” 

Example Phrases

Some example phrases that dermatologists might use to facilitate joint decision-making with patients include:

  • “This is my biggest concern. What is yours?”
  • “We’re going to have to make a choice about what we cover today.”

In general, eliciting patient preferences is the first step to shared decision-making. Using the phrases “I wish,” or “we,” indicates a desire to partner with the patient. Overall, dermatologists can circumvent a variety of potential patient problems by re-affirming a commitment to decide together on a treatment plan throughout the appointment, even if in actuality it is the doctor making most of the decisions. “It may sound something like this: I think you need a different medicine for your psoriasis; I think it will be very helpful, but it has some side effects. Let me explain why I think it would be helpful and what the side effects are, and then we need to decide together where to go from here,” explains Dr. Prose. “That particular phrase ‘decide together’ may be a formality, because in many cases the patient just wants your opinion and will do what you say, but the act of just saying that really changes the conversation. It may even potentially decrease the liability or blame you might otherwise face if the treatment doesn’t work as well as predicted.” 

Another strategic technique for dealing with unrealistic patient expectations is agenda setting. “Agenda-setting is a really essential communication skill for physicians,” says Dr. Shinkai. “I think all providers know well the ‘hand-on-the-door phenomenon’ when you have an encounter with someone, and you’re walking out the door and the patient says, ‘oh by the way I have a concerning mole I need you to look at,’ which turns out to be a melanoma — it starts a whole new visit at that moment.” To avoid any surprise or emergency add-ons to a visit, it is helpful for both patient and physician if the appointment goals are discussed at the outset. 

Agenda-setting may follow the format of: 

  1. Asking the patient’s perspective: what are their concerns for the day?

  2. Identifying the primary conflict or challenge at hand

  3. Naming the emotion or frustration that the patient is experiencing — particularly if all their agenda items are not feasible

  4. Clearly stating the physician’s intentions to prioritize the patient’s health

While there’s not always a realistic amount of time to address all of a patient’s concerns, taking the time to hear them out before outlining your own clinical priorities can go a long way in establishing mutual goodwill. “Just hearing the patient’s concerns can be very important, because sometimes the things we think are at the top of the priority list are not the same as the concerns that the patient really needs to talk about during that particular visit,” says Dr. Shinkai. While providers always want to exercise their best professional judgment in addressing medically urgent concerns first, establishing a rapport with patients can help them from feeling blindsided if the dermatologist determines that a different focus for the appointment is necessary. “I think it’s important to facilitate the visit in a way so that the patient knows what you’re getting at, which is something that dermatologists don’t always know as much about,” explains Dr. Shinkai. “Really setting aside time in which you’re going to decide on the priorities of the visit is key.” 

Agenda-setting can benefit physicians in other ways as well. “Learning this particular skill can help you prevent running over and behind in your clinic, which is something that I think does contribute to provider burnout, so I think it’s a really essential skill from both a provider and patient standpoint,” says Dr. Shinkai. 

What about a patient who is already upset going into the appointment? Pinpointing when a patient encounter is going awry and how to salvage it is key to a successful physician-patient encounter. For example, perhaps an appointment started late due to delays outside of the physician’s control, and the patient is visibly upset. Rather than glossing over the situation, simple acknowledgement of the issue — and the patient’s reaction to it — can be critical. Dr. Prose recommends that dermatologists utilize the following script when walking into an appointment with a clearly agitated patient: 

  1. Say “I’m sorry,” or “I apologize”

  2. Take responsibility

  3. Acknowledge the impact on the patient

  4. Express commitment to improve

  5. Ask permission to proceed

“If one perceives that the patient is upset, instead of immediately becoming defensive or launching into an explanation, what one really needs to do is simply say back what you’ve heard,” says Dr. Prose. “One of the big fears that we all have when we go to the doctor is the worry that nobody’s heard what you’ve said, and nobody’s listening. It’s much better to say, ‘So what you’re telling me is that you’re upset because the medication is similar to the one you’ve had in the past, and you feel that none of the creams are helpful.’ At that point the patient knows you’ve been listening, and it tends to really shift the tone of the conversation in a much better direction.” While this approach may initially take more time than simply proceeding on according to one’s own agenda, it may ultimately save time by diffusing frustrations before they gain sufficient steam to derail the appointment entirely. 

Terms that have different meanings for scientists and the public

While patients often struggle with medical jargon, even seemingly ordinary words or phrases may create confusion among members of the wider scientific community and the public. See the chart below for some examples of terms that carry different scientific and colloquial meanings. 

patient-comm-table.jpg

Source: Physics Today, doi: 10.1063/PT.3.1296

 

MAKING SURE THE MESSAGE IS BEING RECEIVED CORRECTLY

As with many things in life, it’s not necessarily what you say, but you how you say it. Tone, verbal inflection, and phrasing often make a more lasting impression on patients than the technical success of their care (Expert Rev Pharmacoecon Outcomes Res.2012;12(2):149-58).“While the notion of asking permission before explaining things to the patient or moving on to a different part of the appointment is kind of a formality, I always say it’s like borrowing a chair at a restaurant from the next table,” says Dr. Prose. “If it’s available, it’s always ok, but you have to ask. So in the same way, asking permission before explaining is a graceful way of getting to the informational part of the conversation.” 

Patients also often pick up on their physician’s body language, and make their own inferences about the appointment based upon it. Getting off to a good start with a patient can be as simple at choosing to take a seat. “There’s actually wonderful evidence that shows encounters in which a provider is sitting down actually seem longer to the patient than an encounter of the same exact length in which the provider is standing up,” says Dr. Shinkai. (For more tips on positive body language cues, see sidebar.)

More than 40% of patients experience negative health outcomes due to misunderstanding, forgetting, or ignoring health care advice (Ther Clin Risk Manag. 2005;1(3):189-199), and 75% of Americans have trouble taking their medicine as directed, compromising their own well-being and further straining the health care system (Public Health Rep. 2012;127(1): 2-3). However, there are communication techniques that dermatologists can use to boost patient comprehension and improve compliance. One simple way to test whether a patient has correctly understood what’s been discussed during an appointment is to have them “teach-back” to the provider. 

Dr. Prose frequently uses teach-back technique with his patients. “I often take the responsibility on myself, and say something like, ‘I’m not very good at explaining this, so I need for you to say back to me how you’re going to use the cream or how you’re going to take these pills.’ It’s remarkably helpful.” According to Dr. Prose, not only does this method help dermatologists check the patient’s comprehension before they leave the office, but it also helps reinforce the physician’s instructions for the patient, and invite further questions at the end of the conversation. “I think it’s something we don’t do very often, and it doesn’t take very long. People appreciate it, and you’ll learn a lot by hearing back what patients think they heard from you,” he says. 

Example Phrases

Some example phrases that dermatologists might use to facilitate teach-back technique with patients include:

  • “We’ve discussed a lot of points today, and this is a complicated medicine to start. I want to make sure I did a good job explaining it to you; would you be willing to explain it back to me as if you were the physician and I were the patient?”
  • “I’m just going to ask a few key questions to make sure I explained everything well today. So you’re going to use this medication for how many weeks?”

“At the end of the visit, checking patient understanding is really important,” says Dr. Shinkai, “Particularly when you ask them if they have any questions, keep the door very open. One effective way to do that is to ask, ‘What questions do you have?’ as opposed to, ‘You don’t have any questions, do you?’ There’s a subtle but powerful difference in the language there in which the patient is really being invited to ask questions versus being almost shut down.”

Ultimately, better understanding and perceptiveness can go a long way in improving physician-patient relationships. While patients may misconstrue what their providers say, physicians should also be mindful of falling into the same trap, says to Dr. Prose. “I had an acne patient whom I had known for many years, and during one appointment I asked her how she was doing and she said ‘fine.’ When I left the room to talk to the resident, she said to me, ‘You know I think you missed something, because when you asked her how she was doing she was getting very teary, and I’m not sure you noticed that.’ I went back in, asked the question again, and took the time to listen to what she was saying,” he recalls. “It turns out she was terribly depressed and needed help. We actually managed to accomplish getting her referred to a psychologist by the end of the visit, and it’s something for me that reinforced the importance of simply paying attention.”