Diversifying Dialogue: A Physician’s Primer to Procuring all Points of View
Derryl Miller*
Submission: May 2, 2024; Published: May 15, 2024
*Corresponding author: Derryl Miller, Assistant Professor of Clinical Neurology, Indiana University School of Medicine, 705 Riley Hospital Dr., Indianapolis, USA
How to cite this article: Derryl Miller*. Diversifying Dialogue: A Physician’s Primer to Procuring all Points of View. J Yoga & Physio. 2024; 11(2): 555812 DOI:10.19080/JYP.2024.11.555812
Abstract
As physicians, we are challenged with discussing sensitive topics with patients of all backgrounds, ethnicities, identities, and differing levels of trust. Our discussions are emotional. They are often nuanced and uncomfortable. While the patient-physician relationship is protected by confidentiality, our communication with patients must be conducted with caution to elicit complete, accurate, and honest histories of our patients and their families and caregivers. Oftentimes, the care of a patient requires the complex interaction of multiple specialists, a primary team, and the patient’s family in addition to the patient, themselves. This diverse group of people must communicate effectively to provide care to the patient. Oftentimes, the most informed decisions and best care will be accomplished by diversifying dialogue, hearing the voices of all stakeholders in the patient’s care with the patient’s autonomous decision as the final say following informed consent. This manuscript was prompted to help physicians to facilitate open dialogue, to critique and appraise diverse opinions kindly and curiously, and to provide all necessary information to the patient while truly listening and understanding the patient’s wishes to achieve the best of patient-centered care.
Keywords: Patient-Physician Relationship; Confidentiality; Empathy; Decision-Making; Autonomy; Patient Satisfaction; Informed Consent
Introduction
Patient care is a complex process involving interview, education, best evidence literature searches, management of emotions, and cultivating a patient-physician relationship for the pursuit of good outcomes [1]. The physician must be empathetic to elicit an accurate history from the patient, including many intimate topics such as social determinants of health, identity, supports at home and in the area, safety, and resource insecurity [1-3]. Empathy in communication between the doctor and patient allows for reduction in patient distress and the acquisition of rapport, despite the short duration allotted for clinic visits or other time constraints due to patient load and acuity [2,3]. Actively listening to the patient’s chief complaint followed by pointed clarifying questions and seeking to understand the patient’s feelings are required to demonstrate empathy [4,5].
In a prospective cohort of patients, building rapport was most effectively accomplished by asking the patient’s wishes with active listening, reassuring patients with nonjudgemental and matter of fact education, inviting questions with a teamwork approach, explaining results and management plans honestly in patient friendly language, and utilizing interested yet relaxed body language [6,7]. Patient satisfaction is another metric by which physicians are now critiqued through their employers and online [7]. Utilizing effective communication skills both in person and through virtual and phone visits can improve patient satisfaction scores, while additional required visits and unmet patient expectations generally reduce scores [7-9]. A therapeutic relationship for longitudinal care requires listening and validation of the patient’s concerns as well as education regarding technical aspects of care and medical expertise to promote confidence in the provider [10]. Achieving patient satisfaction is especially challenging for patients with deficits in communication, complicating the formation of a longitudinal therapeutic relationship [9,10].
This manuscript is a compilation of the author’s experience with communication and techniques for diversifying dialogue in patient care. The following section is a compilation of six effective techniques utilized in the author’s practice to establish and reestablish dialogue with all stakeholders involved in the patient’s care when barriers to communication are encountered.
Delivering Diverse Dialogue
Ask for Permission
When an encounter begins with a patient and family, it is not always obvious to ask for permission to start [11]. Asking for permission is a small sign of respect and improves the first impression [11]. Many patients have experienced an asymmetric model of control over the encounter with physicians in the past, putting them at odds with a physician seeking to control the conversation for expediency in such processes as consent [11,12]. Starting off a phone encounter or a first time visit with “Is now a good time to talk?” or “Would it be alright if I sit and talk with you?” restores the patient’s autonomy where they previously felt captive [11].
Name The Emotion
Has a patient or family previously been difficult to engage due to silence or needed frequent redirection? Perhaps they seem disengaged or angry and withdrawn because their emotions have not been addressed. In such circumstances, physicians are advised to name their patient or family’s emotion with a phrase such as, “I can understand that this situation is frustrating” or “I think you are feeling a lot of anger or disappointment about this result.” Naming an emotion has not been shown to help with emotional regulation or changing the emotion, but this technique is associated with acceptance of the emotion [11]. Patients and families may continue to feel their emotions but be more prepared to move forward with diagnostic and therapeutic management plans after acknowledging their emotions [11].
Show Interest with Repetition and Ask for More Information
Throughout our careers, we will encounter patients with diverse personality features including those who are highly extroverted or introverted, having widely different communication styles and needs [13]. Whenever the patient or family have little to say about a topic or question, simply repeating their statement to confirm their meaning and follow up with phrases such as, “I’d like to hear more about that”, “Say more”, or “Tell me more” can be very effective [14]. In practice, simply utilizing the phrase, “Say more” even up to 5 times in a row can significantly increase the ratio of listening to talking for the physician which is appreciated by most patients and families [15].
Identify Common Goals
When the patient is suffering and having difficulty coping with a diagnosis or accepting available diagnostic and therapeutic plans, often there is insufficient rapport or incomplete communication to establish common goals. Aligning with patients can be simplified by asking them “What is most important to you right now?” [16]. This question clarifies the patient’s expectations and prepares the physician to either confirm that such expectations are manageable or to make statements aligning themselves with the patient despite unmanageable expectations with “I wish” statements [15,16]. Even if diagnoses, therapies, or outcomes are not what the physician or patient would like to have, statements such as “I wish I didn’t have such bad news today” can align the physician with the patient and establish the framework to discuss common goals [16,17]. Once a patient realizes that the physician wishes their good even with insurmountable odds, they may respond to a simple question such as, “What can I do to help you right now?” [16,17].
Thank Your Patients and Accept Their Gratitude
Oftentimes patients are appreciative of the care we provide, and our response to their gratitude can be very meaningful to them in their recovery [18,19]. Receiving gratitude with a heartfelt “You’re welcome” can build trust quickly and open further dialogue [19]. Physicians can also show gratitude to patients with their time by sitting down in the room, listening attentively, and saying “Thank you for seeing me today” at the conclusion of the encounter [20]. Showing gratitude and receiving gratitude gracefully can also improve patient satisfaction and reduce physician burnout [21,22].
Ask for Perspectives
Many patients and families will feel uncomfortable offering their thoughts, feelings, and desires during appointments or other physician encounters [23]. Simple questions like, “What can I do to improve your stay?” [23], and statements such as “You haven’t said very much, and I want to know what you think about this.” can provide additional valuable perspectives [24]. Physicians must have genuine curiosity, courage to ask, and empathy to elicit all opinions in the room for the development of complete informed medical decision-making [24].
Conclusion
Physicians are scientists, educators, healers, and mediators for patients and families. Our aim in providing patient-centered care is to elucidate all perspectives from stakeholders to provide complete informed consent to all parties and to respect patient autonomy in all decision-making. Our conversations with patients and their families can be uncomfortable, emotional, and challenging. Our refined skills for diversifying dialogue will provide us with the necessary tools to facilitate a positive experience, thorough education at an appropriate level, and empathy in the decision-making process for delivering high quality patient-centered care.
Acknowledgement
I would like to thank my wife, Trisha Miller, who has given me many opportunities to practice curiosity, courage, and empathy in my communication. My relationship with her has prepared me even more deeply to gracefully facilitate emotional patient encounters.
References
- Ha JF, Longnecker N (2010) Doctor-patient communication: a review. Ochsner J 10(1): 38-43.
- Stewart MA (1995) Effective physician-patient communication and health outcomes: a review. CMAJ 152(9): 1423-1433.
- Dugdale DC, Epstein R, Pantilat SZ (1999) Time and the patient-physician relationship. J Gen Intern Med 14(Suppl 1): S34-40.
- Robertson K (2005) Active listening: more than just paying attention. Aust Fam Physician 34(12): 1053-1055.
- Hardee JT (2003) An Overview of Empathy. Perm J 7(4): 51-54.
- Dang BN, Westbrook RA, Njue SM, Giordano TP (2017) Building trust and rapport early in the new doctor-patient relationship: a longitudinal qualitative study. BMC Med Educ 17(1): 32.
- Kern EB (2017) The Birkett Lecture: Avoiding the unhappy patient: The ABCs of rapport building. Laryngoscope 127(11): 2517-2521.
- Wilson SF, Marks R, Collins N, Warner B, Frick L (2004) Benefits of multidisciplinary case conferencing using audiovisual compared with telephone communication: a randomized controlled trial. J Telemed Telecare 10(6): 351-354.
- Jackson JL, Chamberlin J, Kroenke K (2001) Predictors of patient satisfaction. Soc Sci Med 52(4): 609-620.
- Barnett A, Ball L, Coppieters MW, Morris NR, Kendall E, et al. (2023) Patients’ experiences with rehabilitation care: a qualitative study to inform patient-centred outcomes. Disability and Rehabilitation 45(8): 1307-1314.
- Kressin NR, Chapman SE, Magnani JW (2016) A Tale of Two Patients: Patient-Centered Approaches to Adherence as a Gateway to Reducing Disparities. Circulation 133(24): 2583-2592.
- Hall DE, Prochazka AV, Fink AS (2012) Informed consent for clinical treatment. CMAJ 184(5): 533-540.
- Zárate-Torres R, Correa JC (2023) How good is the Myers-Briggs Type Indicator for predicting leadership-related behaviors? Front Psychol 14: 940961.
- Jenkins L, Parry R, Pino M (2021) Providing Opportunities for Patients to Say More about Their Pain without Overtly Asking: A Conversation Analysis of Doctors Repeating Patient Answers in Palliative Care Pain Assessment. Applied Linguistics 42(5): 990-1013.
- Belzer EJ (1999) Improving Patient Communication in No Time. Fam Pract Manag 6(5): 23-28.
- Birk S (2011)Wish Statements’ Help Doctors Deliver Painful News. Caring for the Ages 12(1): 13.
- Quill TE, Arnold RM, Platt F (2011) I wish things were different”: expressing wishes in response to loss, futility, and unrealistic hopes. Ann Intern Med 135(7): 551-555.
- Leopold SS (2019) Editorial: What Do You Say When a Patient Says Thank You? Clin Orthop Relat Res 477(8): 1763-1764.
- Miron-Shatz T, Becker S, Zaromb F, Mertens A, Tsafrir A (2017) A Phenomenal Person and Doctor”: Thank You Letters to Medical Care Providers. Interact J Med Res 6(2): e22.
- Buetow SA, Aroll B (2012) Doctor gratitude: a framework and practical suggestions. CMAJ 184(18): 2064.
- Huang CH, Wu HH, Lee YC, Li L (2019) What Role Does Patient Gratitude Play in the Relationship Between Relationship Quality and Patient Loyalty? Inquiry 56: 46958019868324.
- Lanham M, Rye M, Rimsky L, Weill S (2012) How Gratitude Relates to Burnout and Job Satisfaction in Mental Health Professionals. J Mental Health Counseling 34(4): 341-354.
- Ward HO, Kibble S, Mehta G, Franklin M, Kovoor J, et al. (2013) How asking patients a simple question enhances care at the bedside: medical students as agents of quality improvement. Perm J 17(4): 27-31.
- Hellström O (1998) Dialogue medicine: a health-liberating attitude in general practice. Patient Educ Couns 35(3): 221-231.