Doctor–Patient Communication — Practical Principles

Most of us have heard this term repeated over and over: good communication, not just in a medical context. How do we establish good communication with the patient and, more importantly, how do we objectively evaluate whether it's actually effective?

Because of our own bias, most doctors believe they have excellent communication, while many patients feel misunderstood or unheard. So how can we analyze this discrepancy objectively?

We probably need to ask ourselves what exactly we need in order to communicate optimally with the patient.

First, we need sincere empathy, not a facade and not simple politeness. Patients aren't stupid; they immediately sense if the empathy they're receiving is fake. Our non-verbal communication and our reactions to the patient's emotions give us away. Empathy begins the moment we greet the patient, even before either of us has said a single word. This is probably one of the most important aspects of communication. Non-verbal empathy continues after that initial moment too, and these repeated signals directed at the patient reassure them and make them open up when relating their problem.

In other words, if you don't genuinely care about the patient, you'll never be able to have good communication.

The next important component is the ability not to interrupt the patient, and to mirror them. When the patient is relating their problem, they're an active communicator. They remember the events and tell them. Once we interrupt with a question, they turn into a passive communicator, who just waits for our questions. If we're not able to ask the right questions, we'll lose valuable information.

The mirroring component is one I practice personally. My years as an anesthesiologist helped me refine my communication, since in many situations you only have five minutes—the length of a preanesthetic consult—to earn the trust of a patient who's seeing you for the first time.

What I've observed over time is that if you mirror the patient's feelings, they receive an indirect validation of what they're relating, and they automatically come to trust you. An agitated patient, upset about something, will respond positively if you slap the table and say: "That's not acceptable." A shy, embarrassed patient will benefit if you lower the volume of the conversation, soften your tone, and avoid prolonged eye contact. This way you give them the space they need to open up.

In any conversation, what you want is to gain the patient's full trust.

Once you've listened to the problem, examined the patient, and formed a medical opinion, it's time to communicate it. The way I choose to do this is as if I were talking to a colleague. I explain to the patient, at every step, what I think they have, why I think that, what we should do according to current guidelines, and why we follow them or, in certain situations, why we choose to deviate from them.

This way, the patient becomes an integral part of the medical decision. And that's exactly what the modern patient wants: to take part in choosing the treatment. The days when patients blindly followed the doctor's instructions are long gone. The problem is that if we don't explain why we believe something and how we reach our conclusions, the patient isn't able to make an informed decision. This will frustrate them, make them unsure about the treatment offered, and increase non-compliance as a result.

To give a few examples, I explain to patients why I think their back pain is a benign one, and what symptoms they'd actually have to be experiencing if it were a herniated disc—the condition they fear most.

Or I tell patients who come in with a sore throat, smiling, that in quotes, "today we're going to do something original, something you've probably never done before: nothing." Then I explain the problem with rapid strep tests, asymptomatic colonization, the prevalence of group A strep in children but not in adults, as well as the inability of standard tests to identify group C and G streptococci.

The more a patient knows about their condition, the more easily they'll accept the proposed treatment. For at least a third of patients, I even look up images on Google and explain their problem to them visually.

At the end of the conversation, you need to build safety nets, with clear boundaries and instructions. "This is what I think you have, but if not..." The condition that triggers reassessment needs to be clearly identified. For example: "blood pressure goes above 160 mmHg," not just "your blood pressure is high"; "the nosebleed keeps coming back and doesn't stop after 10 minutes," and so on.

And the action needs to be expressed just as clearly: "Come back to see me even without an appointment," or "Go to the hospital even in the middle of the night."

In this whole chain, we're missing just one component: physical contact with the patient. We're all social beings, and physical contact is one of the things that brings us closer together. In a world where doctors no longer shake hands with their patients, I recommend exactly the opposite. Both at the start and at the end of the consultation, offer the patient your hand. This brief physical contact gives the conversation individuality and makes it personal.

Almost every time, you'll notice that the second handshake is firmer. This is a non-verbal sign of gratitude and trust from the patient—one you lose out on if you don't offer your hand.

Another technique in communication, alongside mirroring, is making yourself vulnerable in front of the patient.

Here we need to understand that any person who comes to see a doctor arrives with limited emotional resources. First, they're going through one of the most difficult moments of their life, and they're forced to share this experience with a stranger. This is where a power imbalance appears.

A patient who comes in embarrassed to present a perianal skin fungal infection, or another who has to talk about their chronic depression and suicidal thoughts in front of a successful, well-groomed doctor who's often perceived as wealthy, will automatically run into a communication barrier.

What I personally do to reduce this distance between us is share something vulnerable about myself. For example, I might tell the patient that a skin fungal infection has nothing to do with personal hygiene, and that I myself, at 16, had a groin fungal infection—which happens to be perfectly true.

Or I explain that roughly 30% of the population suffers from depression, and that in 2012, when I moved to Germany, I had a panic attack one night, convinced I wouldn't be able to adapt culturally. At the time, I didn't even realize that this anxiety was the reason I was lying awake at night, unable to fall asleep.

This approach surprises most patients, but at the same time it helps them understand that the difficulty they're currently going through doesn't define them as people.

In the end, it's actually quite simple to have good communication with a patient.

1. Shake the patient's hand.

2. Be empathetic. You have to genuinely care.

3. Let the patient speak actively and don't interrupt them prematurely.

4. Mirror the emotions they show, even if you don't agree with their ideas or beliefs.

5. Clearly explain how and why you arrived at the diagnosis, and how and why you're recommending the treatment.

6. Build safety nets for situations where you're wrong, and communicate openly that this possibility exists.

7. If the patient comes to you distressed and with limited resources, you need to step down off your own pedestal. And the only way to do that is by putting yourself, in turn, in a vulnerable position.

   
   

This is my guide to what I believe communication between doctor and patient should look like.

Don't forget that roughly 90% of complaints against doctors stem from poor communication, not from an unsatisfactory medical act.