Patient centred communications

This involves developing trust and rapport in key practice relationships between the:

• doctor and patient
• nurse and patient
• staff and patient.

A growing body of research also indicates that effective communication plays a key role in the prevention of complaints and litigation. It is also important that there is strong communication between the people providing healthcare in the practice. That means between the doctor, the nurse or other clinical staff and administrative staff. If communication between all areas of the practice is powerful, many issues can be pre-empted and strategies to manage patient concerns implemented.

The practitioner’s verbal and non-verbal communication style and skills influence the patient’s perception of the quality of care. As patients may not necessarily have the knowledge to enable them to judge a practitioner's clinical competence, the patient’s assessment of the service delivery provided could be used as measure of your competence.

An important precursor of dissatisfaction is inadequate or inaccurate information and communication. It is critical that there is 'consistency of message' delivered to your patients.

In general, if the relationship between the practice and/or a doctor and patient is strong and an adverse event occurs or a patient’s expectations are not met, patients are less likely to be dissatisfied with your care and more understanding of the outcome. Research indicates that the patient who feels abandoned in these circumstances is the one who is more likely to complain or commence an action against the practitioner.

Patients expect that the:

practice will provide them with:

• timely access to their doctor
• a fee that reflects the nature and quality of service provided
• services that the practice promotes
• professionalism and common courtesy.

doctor will provide them with:

• adequate time
• a genuine interest in their problem
• a willingness to listen
• expert medical advice and treatment
• understanding, responsiveness and compassion
• respect
• helpful and supportive practice staff.

Anger and frustration are major drivers of complaints, with patients making statements such as the below:

• The doctor didn't listen.
• He/she wouldn't talk openly with me.
• He/she is hiding something from me.
• I never received explanations.
• I was ignored.
• I couldn’t get in to see my doctor.
• The service cost too much for what I received.
• I felt rushed during my consultation.
• Staff were unhelpful or rude

Building an atmosphere of mutual respect in the practice will assist in the event that something unexpectedly goes wrong. If there is effective communication with the patient it will assist in dealing with, and resolving, the situation at hand. The practice should promote their expectations when a patient commences with a doctor at the practice. Like many hospitals, practices are now providing mutual expectation information brochures.

Practice managers who recognise that some patients or situations are more difficult to handle than others should consider attending and providing to staff, one of the range of communication workshops that are offered through a variety of professional organisations (AAPM, Avant, Medicare Local, RACGP). Effective patient communication across all aspects of patient care within the practice, strengthens the trust that is established with patients in serving their healthcare needs.

What a patient expects of the treatment/advice that a practice/practitioner provides can be influenced by one or more of the following factors:

• The patient's previous experience with illness and healthcare providers. For example, has the patient been seen previously by a practitioner with whom their expectations were not met?
• If the patient perceives they are at risk for a particular problem, whether it is due to their current history, age, family history or lifestyle. For example, a patient may perceive that because they have abdominal pain they are at risk of developing bowel cancer because their uncle had exactly the same symptoms when it was diagnosed in him.
• Information from relatives, friends and various forms of media such as television or the Internet (“Dr Google”!). Although some of this information is correct it may not be the most suitable treatment for the patient under their circumstances.
• If you or a practitioner can determine that a patient’s expectations have evolved from one of the above factors, then you can focus on where the discussion needs to be directed.

Learning to become an effective communicator does not always come naturally to practice managers, practitioners or their staff. It is not always an easy task, particularly within the challenging and demanding environment of a busy medical/surgical practice. There are some techniques that can be useful to facilitate and encourage an enhanced relationship with practice patients.

1. First impressions count! Getting the 'front end' right should be part of every management plan for you and your practice. Patients start formulating their opinion about the practice and their practitioner from the moment of first contact. This opinion is based on the entire 'cycle of service' which encompasses:

   • the first point of contact with the practice (usually by phone with the receptionist)
   • the first direct face-to-face contact at the reception desk.
   • the consultation process
   • the invoicing process (post consultation)
   • any recall/follow-up services.
   
   

   The ‘cycle of service’ should be viewed from an overall perspective of practice staff contact, products/services and processes/systems that support the core business - the medical consultation. Throughout the 'cycle of service', all staff and doctors must ensure they maintain the 'consistency of message'. Issues arise for patients when they hear different information from different people; this is especially so for doctors as many patients will respond with the phrase “... the doctor said ...”

2. The moment the patient phones, contacts or attends your practice to make the initial appointment is the ideal time to familiarise the patient with your practice and its policies.
   
   Provide new patients with written information in the form of a pamphlet/brochure that familiarises them with your practice. This can assist in avoiding misunderstandings, unrealistic expectations and complaints about ‘service’. You might include the following:

   • practice hours
   • appointment scheduling
   • key practice staff details
   • the days and hours of work of each doctor
   • after-hours or emergency care availability
   • mutual responsibilities and expectations
   • zero tolerance policy
   • home visits availability
   • requirement for patients to advise staff when a long consultation is necessary
   • requirement for patients to advise staff when their appointment cannot be kept
   • whether the doctor will take telephone calls during consultation hours and/or when they will be returned
   • the procedure if the doctor is delayed or called to an emergency
   • whether medical information and/or test results are available by phone
   • policy regarding repeat prescriptions
   • practice fees and billing arrangements
   • information regarding referral requirements
   • other healthcare/allied health services available
   • information regarding privacy and confidentiality
   • any other relevant information you would like patients to be aware of.

3. Advise and apologise to your patient if the doctor is running behind for their scheduled appointment.

4. Listen to patients and respond to their needs and preferences.

5. Respond to patients in a way they can comprehend and understand.

6. Empathise: acknowledge their situation or concern.

7. Use silence effectively, allowing patients enough time to express thoughts or feelings.

8. Explore: ask the patient questions and invite them to ask you questions, ask their opinion and seek their expectations. Ask the patient to repeat to you what they have understood of your discussion.

9. Focus: don’t make the patient feel rushed. The last thing staff or a doctor should do when pressed for time is to behave as if pressed for time. The patient is more likely to leave the consultation with 'unfinished' business.

10. Discuss: encourage the doctors to explain what they are thinking and openly discuss their proposed management and treatment plan. Patients about to undergo a procedure should be informed what to expect during and after treatment. Consider the following examples:

    • Discuss the possible side effects and how they can be managed and dealt with.
    • Provide instructions as to when the patient should seek advice after a procedure.
    • Discuss the consequences of not complying with instructions.
    • Provide information on follow-up appointments. Advise if assistance will be required after the procedure.
    • Advise the patient if time off work or away from other responsibilities will be required.
    • Ensure the patient has a clear understanding that the final desired outcome could take some time.
    • Inform the patient of all possible fees. Have a “talk money up front” policy. There should be no surprises in relation to fees.

11. Seek understanding: provide the patient with options and the time to consider them. Determine the patient’s level of understanding by using a questioning strategy that will allow you to identify any deficit in this regard.

12. Encourage feedback: feedback from patients can be obtained either from complaints/compliments received or through structured patient satisfaction surveys. While actively seeking feedback from patients will elicit both positive and negative responses, the information obtained is invaluable in directing and supporting practice improvement. This can also be an effective mechanism for communicating with and obtaining the patient’s opinion of your service.

    You must make sure, wherever practicable, that arrangements are made to meet the patient’s language and communication needs. Where particular arrangements need to be made for patients, it is best to have these in place for when the patient attends for their consultation.

13. Complaints handling systems: avoiding complaints would be the ideal, however the reality is that you will probably encounter a complaint at some time in your career. It is important to have a protocol in place for handling complaints and for dealing with them promptly and professionally.

14. Manage patient expectations: staff and doctors can be drawn into arguments and then give in to patient demands “because they felt sorry for them” or wanted to “do them a favour” or just could not say “no”, against their clinical judgement. In the long run, this places a great deal of strain and pressure on the staff and doctor and sets up the patient’s expectation for treatment in future consultations. For instance, there are limits to what medicine can achieve: some illnesses cannot be cured, advertised medications or procedures may not be suitable for a particular patient, or a cosmetic procedure may not restore a patient's happiness.

Managing unrealistic expectations is about assessing the situation and thinking about points such as the following:

• Why does the patient want this particular treatment? What do they want as an outcome? Exploring this will determine where you need to direct your communication.
• Take a step back and detach yourself from the patient’s emotions, demands and expectations so that you can make considered decisions about the most appropriate treatment.
• Establish a connection with the patient. Empathise and validate the patient’s emotion, whether it is anger, frustration, hostility or resistance. If you are able to acknowledge the patient’s feelings and understand why they think the way they do, this paves the way for a more collaborative relationship.
• The key question to ask of the complainant is: “What would like to see happen now to resolve this issue?”
• If you receive a complaint, you need to ensure that it is the patient who is complaining and not a family member, spouse or relative. You have confidentiality issues that must be considered and relate specifically to the patient.

As a practice manager, allow staff the authority to deal with difficult situations where they are able to cope with those situations. Alternatively, you must be available or have systems in place to allow staff to seek assistance if a situation escalates and they require assistance.

You need to be authoritative: sometimes a patient's behaviour may concern you. Not only is this a challenge to deal with, but staff and waiting patients may find it distressing. It is important to set limits and boundaries and no matter what the cause, you and your staff should not tolerate unacceptable behaviour. You may refuse to deal with a patient until they have calmed down and are prepared to speak reasonably to you. In extreme cases, you may be required to send them away or call for help from staff or the police.

It is easy to label a patient as ‘difficult’ because they express anger, hostility, are demanding, have unrealistic expectations, are not likely to be compliant, are ‘doctor shoppers’ or have had repeated procedures for the same problem.

While doctors are within their rights to refuse to treat that patient, it is important to establish the reason behind the patient’s behaviour before deciding to decline to manage them. An open and honest approach is the best way to gain the patient’s trust and they may be more likely to tell you what is going on.
There are some patients who may continue to be disruptive and non-compliant despite all the measures you take. You may feel that you are not the practice and the scheduled doctor is not the right doctor for them and that they would be better managed by someone else. However, there are some situations in which you cannot make this choice. These include:

• when the doctor is the only specialist who offers a particular service: they do not have to provide the service against their clinical judgement, except if the condition is life-threatening
• when the doctor is the only practitioner in that area
• in emergency/life-threatening situations where harm is likely to occur if no intervention is provided.

Practices and practitioners cannot deny access to their practice solely on the basis of race, ethnicity, religion, HIV status, sex or any other reason which falls under anti-discrimination legislation.

If a patient has been referred to one of your doctors and they decide they do not want to manage this patient, it is best to refer the patient back to their referring practitioner rather than suggest another practitioner. This will ensure your practice/doctor maintains good relationships with your peers by not referring ‘difficult’ patients, and also keeps the referring practitioner informed.

Travaline, J et al. Patient-Physician Communication: Why and How J Am OsteopathAssoc January 1, 2005 vol. 105 no. 1 13-18 http://www.jaoa.org/content/105/1/13.full

Fong, J and Longnecker, N. Doctor-Patient Communication: A Review Ochsner J. 2010 Spring; 10(1): 38–43.

Sullivan Colleen & Geoffrey G Meredith, Successful Practice Management: Exceeding Patient Expectations, Lulu, 2012