Improving the physician-patient relationship with compassionate communication

By Emily Margosian, Assistant Editor, January 1, 2022

DermWorld talks to Christine J. Ko, MD, FAAD, professor of dermatology and pathology at Yale School of Medicine, about how to use psychology to improve patient interactions.

DermWorld: What drew you to this topic?

Dr. Ko: I ‘grew up as a doctor’ in a more paternalistic model of patient care. Approaches like narrative medicine and patient-centered care weren’t what I was taught during training. There’s not necessarily anything wrong with the paternalistic model, but it doesn’t necessarily have the patient as a human being at the center of the interaction. I wasn’t aware of these concepts; I was focused on learning how to be a good doctor, and I thought that mainly meant learning about disease, treatment, and how to make the correct diagnosis. My perspective changed when my son had a medical condition.

Dr. Ko: He’s profoundly deaf. In a nutshell, he had a misdiagnosis until he was 22 months of age and finally got the correct diagnosis of auditory neuropathy. Until that point, I had been told by different practitioners that he was fine. Auditory neuropathy was mentioned to me for the first time as the doctor was walking out of the room. I had asked, “Is there something where you hear sometimes, and other times you don’t?” She turned with her hand on the doorknob and said, “Well, there’s auditory neuropathy, but it’s so rare. Do you want him to have general anesthesia? He needs imaging for that under general anesthesia.”

In retrospect, I realize she — not deliberately, I’m sure — confused me with a different question of whether I want my son to have general anesthesia, which has significant risks. I thought, “Of course, I don’t want him to have general anesthesia.” However, if she had said, “Well, there’s auditory neuropathy, but it’s rare, and there’s a special test that needs to be done. Do you want to have the right diagnosis?” I would have said, ‘Absolutely.’ There was a communication failure on both our parts.

Over time, I’ve come to realize that while the doctor is knowledgeable in the diseases that they’re an expert in, the patient — or the patient’s family — are experts in their experience. There is authority bias; there are multiple things that are going on with both sides. I have become more aware that in each moment there can be opportunities to change health care interactions for the better.

DermWorld: What strategies do you use in your daily practice to better communicate with patients?

Dr. Ko: Sometimes I think that my techniques are too simple (others have written about them as well), but I’ve received feedback that these strategies have been helpful to my colleagues as well. One technique is to take a breath before entering the room. It’s a habit now that I’ll put my hand on the doorknob and pause before I go in and see the patient. That has helped me to establish presence and mindfulness before a visit.

Another example is to make eye contact. I thought I was making eye contact, but I don’t think I was doing it in quite the same way that I do now. One simple trick is to note the eye color of the patient when you walk into the room. That forces eye contact and can become a habit. I’m a strong believer in creating habits. Patient eye color is the first thing I try to note instead of looking down at a paper or making a beeline for the electronic medical record. There’s naturally something about looking into someone’s eyes that makes me want to smile, and usually the patient smiles back. It’s a quick thing, but it’s made a big difference for me.

DermWorld: Do you have an example of how putting these tactics in place has refocused an initially challenging patient interaction?

Dr. Ko: I recently had a new patient who was very angry with me right when I walked into the room. I wasn’t running late that day, and I had never met him before, so there was no reason for him to be upset with me. For some reason, he thought he was coming to see his kidney doctor, so when he got to the appointment and found out he was seeing a skin doctor, that made him extremely upset. I named his emotion, and I said, “You seem really angry.” He said, “Of course I'm angry. I need help with my kidney, not with my skin.” I apologized, and said, “I’m sorry, but I’m not a kidney doctor. What I can do is end the visit right now, take you to the front desk, and we can make an appointment with your kidney doctor. I can let them know that you need to see them right away, but that’s the extent of what I can do.” He was still upset, and stormed out, but it was helpful for me to name the emotion and realize that I could choose a response for myself other than anger.

Interestingly, about 30 minutes later, he came back and apologized to me. I was so surprised, but I took this as feedback that I had handled the interaction well enough in his eyes. I was also grateful that I had handled the interaction well enough from my viewpoint too. It hadn’t ruined my day. I had been able to easily move on to the next patient. It was a lesson that these techniques I’ve developed much more recently in my life have had an impact in changing the way an interaction goes for the better on both sides.

DermWorld: Why is it important for physicians to communicate compassionately with patients?

Dr. Ko: I think you need to recognize that there’s a real human being in front of you. That person is not just a diagnosis. There’s value to the process. Doctors are problem-solvers — the patient comes in, they describe their symptoms, and you try to solve it. However, I think focusing too much on that alone dehumanizes the patient, and it also dehumanizes the doctor. Compassionate care is bringing that human side into it. What patients really care about is whether their doctor cares.

DermWorld: Your recent book promotes the idea of ‘using psychology to optimize health care interactions.’ Could you give some examples of how that might play out in practice during a patient encounter?

Dr. Ko: I never took psychology as an undergraduate, and I think I totally missed out. I had what I think of as a crash course in cognitive psychology in little bursts over the past decade and a half. I started with visual recognition, and the cognitive psychology of how you can see and take something in. Daniel Kahneman, a Nobel Prize winner in Economic Sciences, has written about what he terms ‘fast thinking’ and ‘slow thinking.’ For example, in terms of visual recognition — which I think dermatologists can really understand — when you walk into a room, and you look at someone’s skin, you know immediately what they have. You can do that because you have a certain amount of expertise. That’s ‘fast thinking/seeing,’ and it’s valuable. That’s what we are trying to get trainees to learn how to do. Then there’s ‘slow thinking,’ which is when you walk into the room and it’s unclear. The answer doesn’t pop up right away, but you use different methods to figure it out, say doing a biopsy for example, but also listening to the patient. The patient is basically telling you everything you need to know.

I realized — through building my son’s speech and language — that listening is a skill. We used this technique called auditory verbal therapy to create a ‘listening habit,’ meaning to acclimate his brain to recognize sounds he’s not used to listening to, ultimately creating a habit of listening. Years ago, I was talking to another parent, and she said, “It’s like figure ground separation. Listen to the voice, rather than the background noise.” I thought, oh my gosh, that’s the same thing as visual recognition. There’s a figure, and there’s ground. There’s the rash, and there’s the background skin. I remember that was like a big ‘a-ha’ moment for me. In the same way that I taught myself to be a better observer of skin disease, I could be a better listener by developing the skills to do so.

There’s also a lot to be said about body language. One tactic I use now is determining whether a patient’s body language is consistent with what they’re saying. For example, if I say, “Ok, so do you want to take this medicine?” and they respond, “Sure,” but seem very closed off, then the better thing for me to do is to respond, “You’re saying yes, but I’m not sure that you’re really on board.” I try to take information from their body language and integrate it with the sounds that I’m hearing.

DermWorld: From your perspective, how has COVID-19 affected the physician-patient relationship?

Dr. Ko: COVID has completely affected health care, as it has with all of life. Patients have had to be more patient, unfortunately, because the health care system is overloaded, but I also have had to be more open because of it. I’ve had some personal challenges during this pandemic, and have had to move patients around, or sometimes have taken longer to respond to their messages. I’ve been more open with my patients and have revealed my own humanity in the sense that I’ll apologize and give a brief explanation like, “My son really needed me,” or, “My son had an appointment himself, and I’ll need to move things around.” I have never yet encountered a patient becoming angry, or who didn’t have compassion for that as well. I think that despite feeling sometimes an impossible amount of burnout, that change in dynamic has been truly renewing. The sense that we’re all in this together has had a huge impact on health care interactions, for better or for worse.

Christine J. Ko, MD, FAAD, is professor of dermatology and pathology at Yale School of Medicine. Her book How to Improve Doctor-Patient Connection is available through Amazon or from Routledge. Use promotional code FLY21 for 20% off.

Additional DermWorld Resources