Building the doctor-patient relationship

‘Communicate better’ is an instruction that is often touted as the solution to avoiding a complaint. It is true that poor communication leads to all sorts of problems, from failure to obtain an accurate history that leads to misdiagnosis, to misunderstandings and incorrect assumptions of the patient’s circumstances, to ideas around management and cultural insensitivity that leave patients feeling that they have not been listened to. You can see how a complaint might arise, even if your medical practice was bio-medically acceptable or if there was not an adverse outcome. Essentially, your patient is annoyed that your communication did not meet their expectations.

Therein lies the crux of the matter – patient expectations will vary, and you may not recognise that you’ve failed to meet them. We all have patients that tolerate poor communication; patients whose belief in doctors and the wonder of modern medicine is higher than our own. Their relatives and loved ones however, perhaps not present at the time, will not be as tolerant in the event of an adverse outcome.

So how are we meant to ‘communicate better’ and what does that mean? At its heart, as with all medicine, is the idea of relationship. The doctor-patient relationship is the vehicle by which medical care is delivered, and this applies to everything that we do. The two sides of the relationship will not always be balanced (an unconscious or anaesthetised patient is quite literally, in our hands) but in the wider picture of their care, the doctor-patient relationship is the key to our work. ‘Communicating better’ means attending to the relationship.

The starting point to building and maintaining a therapeutic relationship is to quite simply be quiet. Shut-up and listen! Don’t interrupt your patient as they are trying to tell their story. Use facilitating open-ended questions like ‘tell me about that’, or ‘can you describe that to me’, or even ‘go on …’ but essentially, be quiet until the patient has exhausted their description of their situation. You then need to use closed questions to explore the biomedical aspects that you need to do your work. Occasionally, a patient will ramble off topic, but it is easy to gently return them to the issue at hand. Not interrupting means that other components of the problem come to light which may never have even crossed your mind; components that might have led to all sorts of problems had they not been mentioned. The link to complaints avoidance is self-evident.

By being quiet and listening attentively, your patient will feel heard. The relationship is deepened, and now you can take the next ‘communicate better’ step, which is to explore how these issues are impacting the person of your patient. What impacts are they feeling in their work, their family and other important relationships, their hopes and aspirations for their future, and all those unique characteristics that cannot be assumed and that define personhood? If you take a few moments to do this, not only will you arrive at a deeper understanding of your patient’s illness experience, but they will also feel that you care and as the consultation progresses, your management plan will have been negotiated, mutually agreed and even in the event of an adverse outcome, less likely to result in a complaint.

That is what ‘communicate better’ means.

Dr. Wayne Cunningham

General Practitioner