Patient–physician relationship – Communication is the key

“The patient will never care how much you know, until they know how much you care” – Terry Canale (2000 American Academy of Orthopedic Surgeons Vice Presidential Lecture)

Patient–physician relationship is a complex psychosocial interplay of vulnerability, trust, and authority in a professional setting. It has been legally defined as “a consensual relationship in which the patient knowingly seeks the physician's assistance and the physician knowingly accepts the person as a patient.”[1] Patient–physician relationship is fiduciary, in which a physician is trusted to provide an accepted standard of medical care in his or her area of specialization.[2] Physician's obligations are to duly inform the patient of the medical condition, to provide optimal treatment, to refer the patient to an appropriate specialist if necessary, and to obtain the patient's informed consent for medical treatment or surgery.[3] Physicians are influential in deciding if, when, and how healthcare services are delivered, and the balance of power is tipped in favor of the physician.[4] Patients are, therefore, vulnerable when they entrust physicians with their health and lives. Trust is the keystone in such an asymmetrical relationship.[5]

If trust is the defining element of patient–physician relationship, communication is the means to engender trust.[2] Effective communication improves patient and physician satisfaction, reduces medical errors, decreases patient complaints and medical negligence claims, improves patient compliance to medication and treatment regimens, and has an impact on the overall clinical outcomes and patients’ physical and mental health related to their diseases.[6,7] As we move away from the paternalistic approach to the practice of patient-centered medicine (treating the patient as a person with shared power and responsibility and forming a therapeutic alliance), ongoing communication becomes the facilitator in cementing the new equation of equality and partnership in patient–physician relationship.[8]

An open two-way communication has an important bearing on all the four vital aspects of the depth of patient–physician relationship that govern patient satisfaction – trust (those who trust that the physician has the highest level of satisfaction), knowledge (patients report a high level of satisfaction when the physician allows the patient to give information and understands and specifically addresses their concerns), regard (perception of physician's friendliness, warmth, emotional support, and caring are directly associated with patient satisfaction), and loyalty (continuity of care improves patient satisfaction).[9] Apart from the depth of patient–physician relationship, longitudinal care (seeing the same doctor with ensured continuity of communication and medical care) and consultation experiences (patient's encounter with the doctor at the time of medical consultation) are the main processes by which patient–doctor relationships are promoted.[9] All these obviously would deeply involve elements of communication.[5]

Physicians, however, do not seem to be very good communicators.[7] They receive very limited formal coaching in patient communication skills, yet perform an average of 100,000 sessions of patient communications in their professional span.[7] Apart from the lack of formal training in communication skills, undue reliance on tests and investigations, practice of defensive medicine, conflicting interests of clinical and financial targets, and the influence of print, electronic, and social media act as barriers and distract from the core human interaction between the physician and the patient. In 1998, the American Academy of Orthopedic Surgeons conducted a survey which found that the patients perceived technical skills as important but valued communication skills equally important.[7] According to this survey, while 75% of the surgeons believed that they had communicated satisfactorily with their patients, only 21% of the patients expressed satisfaction with their surgeons’ communication skills.[7] This gap in perception between the surgeons and their patients was most evident in categories such as listening and caring, and the time spent with the patient.[7]

The good news is that communication skills can be intuitively acquired by any sensitive individual capable of introspection and contemplation or can be inculcated by formal training. It is essential that physicians must invest time and energy in improving the quality of communication with their patients. Epstein suggests that “communication should be simple enough to be generally understood; complex enough to account for clinical reality; designed to involve different types of patients, families, clinicians, and healthcare systems.”[10]“Communication is not necessarily what we say, but it is more about how we say and how the patient interprets what we say.”[2] It is believed that only about 7% of communication is transmitted verbally, and 38% is communicated nonverbally through expression and gestures.[2] Pellegrini encourages physicians to use every communication tool that they have available – “It is how we look at a patient. It is how we act with a patient. It is how we smile. It is how we listen. It is how we show empathy. It is how we show compassion. It is about delivering on a promise, even if a small one. It is about reaching out to the patients after they have left the hospital or the clinic in any way possible, and letting the patient know, without doing so overtly, that we care.”[2] He goes on to state that “every single encounter with another human being gives us a unique opportunity to do something good, to make someone feel better, or to improve the image of our workplace, and allows us to build trust at every encounter, every time, no matter how small or how big the opportunity or the result might be”.[2]

“A patient–physician relationship is sacrosanct where the patient reposes trust and confidence in a physician to cure, protect against, or palliate illness.[4] The patient has feelings, wishes, desires, hope, and, sometimes, ambivalence or defiance.”[4] However, evidence suggests that physicians often remain emotionally distant, technical in approach, organ- or tissue-focussed (as in ophthalmic subspecialties) and technology-oriented in their interactions with patients.[11] Healthcare organizations increasingly refer to patients (or consider them) as “customers” which wrongfully prioritize monetary considerations over optimal professional medical care and take advantage of patients’ vulnerabilities.[4] Medicine should remain a profession and not become a business. As duly emphasized by the American sociologist Everett Hughes, “medical profession should ideally go by the motto of credat emptor (let the buyer believe or have trust) instead of caveat emptor (let the buyer beware).”[4,12] Good communication can hopefully help reestablish the patient's trust in physicians, for trust is vital to heal.