Perceptive Chapter: “Are We Listening?” - Improving Communication Strategies and Relationships between Physicians and Their Patients

Abstract

We talk about the “art” of medicine because medicine is more than science. The science portion drives diagnosis and treatment. However as more tests become available, the art of the relationship and communication with patients is being steadily lost. Physicians often interrupt their patients only seconds into the interview. If we stop their story that quickly, we are not listening to what they have to say. If we do not listen to their story, how can we understand their illnesses and the effects on their lives? This chapter will examine physician-patient relationships by looking at ways to help foster these relationships and what can hinder them. We need to actively listen to our patients, listening for clues about their illness and/or suffering. We need to use observation and our emotions to understand the context of their illness. Examples will be included to help elucidate some of the challenges. Models that can provide a framework for communication will be discussed. Suggestions for ways to help improve communication and interpersonal relationships between physicians and their patients will be offered. This chapter will provide a chance to think about improving communication with our patients to help strengthen our interpersonal relationships.

1. Introduction

When physicians practice the “art” of Medicine, the art portion includes well-developed diagnostic skills to sleuth out the cause of a patient’s complaint. However one of the most important aspects of the “art” of Medicine lies in communication skills between the physician and patient. It takes more than just a stethoscope, an X-Ray, or even an MRI to get to the heart of a patient’s story. It is from the lines of the story that a clearer diagnosis can be made. It is by understanding a patient’s values and beliefs that we can work to craft treatment options that align as closely as possible to their goals. There is an art to developing good relationships between physicians and their patients, which is vital in the practice of medicine.

However as more tests become available, the art of the relationship and communication with patients is being steadily lost. Within patient encounters, doctors only elicit the patient’s agenda for the visit 36% of the time [1]. Also striking was that even when the patient’s agenda was obtained, patients were still interrupted seven out of 10 times at an average of 11 seconds [1]. If we stop patients that quickly, we are not listening to what they have to say. When patients are not interrupted, the meantime to describe their concerns is 92 seconds with 78% of the patients finishing their story in 2 minutes [2]. A very small minority of patients took 5 minutes to tell their stories, but in all cases, whether 2 or 5 minutes, the physicians felt that important information was provided [2]. Physicians are under time pressure with many follow-up visits in the United States only scheduled for 15 minutes. It is understandable that physicians feel like they need to jump in and direct the conversation. Yet if patients are given space to describe their concerns, they feel more listened to and physicians can gain valuable information. Good communication can improve the relationships between physicians and their patients. Having good relationships with our patients can help with a physician’s overall job satisfaction [3]. Those personal connections help us stay in touch with why we entered into this profession. So listening, understanding the patient’s story, and connecting with the patient benefit both patients and physicians.

How do we do this? Asking more open-ended questions can allow for a more accurate story without necessarily taking additional time. Physicians, though, worry that they will run out of time or lose track of the interview if they give patients too much space. I have witnessed this when supervising residents. One resident would start with open-ended questions during most of the new patient evaluations, until the evaluation when I was supposed to be scoring her. Then she started with very close-ended questions and led the patient through the entire interview. During our debrief, I asked what had happened. She described feeling worried that she would run out of time since she had only 40 minutes for the timed interview. However in our previous encounters when she allowed the patient to talk more freely, the interviews lasted about 45 minutes and we had a more complete understanding of the problem. For example, Haidet and Paterniti [4] describe history building rather than history taking. The authors diagram two interviews, one that focuses quickly on yes-no questions and one which allows the patient more room to tell his story. They both take about the same amount of time but the one in which the patient is allowed more space, a clearer story is provided, which also includes identifying some of the patient’s underlining fears. When we address a patient’s fears, they feel more listened to and supported. Overall good communication during the visits can lead to improved patient satisfaction [5].

The physician’s goal in most clinical encounters is to discover what is objectively wrong and work to cure it. However, if we do not understand the patient’s subjective experience of the problem, then a large portion of their concerns is not addressed. We do need to find a balance. We do not want to treat the illness without treating the individual but on the other extreme, we do not want to become so paralyzed by our patient’s emotional reactions to their illness that we cannot offer them support. In ref. [6] we see the shift and balance that needs to take place in interviews so that the illness is addressed, the patient is supported, and the doctor is not overwhelmed. The author takes the reader through his encounters with different physicians as he deals with a diagnosis of Guillain-Barre Syndrome to highlight how to diagnose and treat the illness without losing track of the patient.

When my mother was ill, I experienced the distress that can come when a physician focuses on the disease but forgets the human element. My mother had been experiencing significant nausea. I was talking with her primary care physician about the next step and it was decided to pursue a brain MRI because the nausea was not responsive to any of the GI remedies. I still remember being in the clinic and having the physician reach out to me. She asked me excitedly if I had seen the results of the scan. I had not. She informed me, “You were right. They found a tumor in her brain.” That was how I found out that my mother had glioblastoma. At that moment, I was a colleague and we had solved the medical mystery. What was forgotten is that I was the patient’s daughter. I had an emotional reaction to this news. We need to not only listen to our patients but remember the humanity of our connection.

Sir William Osler said, “The good physician treats the disease; the great physician treats the patient who has the disease.” Being a great physician is practicing not only the science but also the art of Medicine. We need to understand the importance of the relationship. We need to listen to and appreciate our patients’ unique stories. This chapter will discuss techniques, such as active listening, consider potential impediments for developing relationships with our patients, and consider strategies to improve those relationships. The examples and many of the techniques are taken from work within the United States. While there may be cultural differences and approaches that need to be considered in different countries, many of the tools will be appropriate for all physicians. All of us can benefit from listening closely to our patient’s stories, seeing them as unique individuals, and developing therapeutic relationships that can benefit both patients and physicians.

2. What makes a good doctor?

McLeod [7] seems to embody Osler’s quote when he distinguishes between disease and illness. The disease is the medical aspect; it is the diagnosis. Illness is the patient’s experience of the disease. This can include pain or limitations in one’s life. It relates to the emotional reactions of vulnerability and fear. Illness can change how an individual looks at herself and how others look at her. The disease is only part of her story. However, we, as physicians, can forget that. In the field of eating disorders, we are careful to describe our patient as “a young woman struggling with anorexia nervosa.” She is not an anorexic. This simple change in the order of words outlines that an individual is struggling with a disease. She is not completely described by it. Yet on medical rounds, patients become the “MI (myocardial infarct) in room 10” or the “asthmatic.” When we talk about patients as their diagnoses, we take away their humanity. That can push physicians to treat the disease without considering the patient and their experience of their illness.

When considering what makes a good doctor, physicians tend to focus on medical skills, whereas patients focus on communication skills [8]. Defining what makes a good doctor can be difficult and may depend on the stakeholder. Yet, perhaps, we can consider some elements. Patients want physicians who can make them feel at ease, are empathetic, and can remain calm under pressure [8]. A systematic review found that patients want their doctors to have “a positive outlook on life, a good sense of humor, a well-balanced temper, and love for people” ([8], p. 400). That sounds like fairly high expectations. I remind my students that our patients want us to be engaged with and interested in what they have to say. They want us to see them as unique people and to be curious about anything in their story that could contribute to a better understanding of their illnesses and their lives. When we demonstrate caring, we earn the patient’s trust. This includes following up on clues that alert us to patients’ concerns [9]. Clues are hints at parts of the story that affect a patient but which he is not certain the doctor will find relevant. Patients offer these hints both verbally and nonverbally. Perhaps, they will say that there is a “lot going on.” It is then up to the physician to ask about that. If we do not, then that part of the story will probably stay hidden. The patient will feel that the doctor is not interested. They will sense that we are not really listening.

We have to recognize that each patient will have a different experience with their illness. Some of this may be based on their past history—perhaps another family member or friend had similar symptoms. If that is the case, patients may worry that they also have whatever disease or outcome that befell that individual. If someone had these symptoms and was diagnosed with cancer or experienced a significant negative outcome, they may come to the physician with significant fear and a very different interpretation of what is occurring. We need to understand their fears to help them navigate the experience [4, 7]. Physicians often forget that even though we may have seen and treated this disease numerous times, this is the first time for this patient. We jump in with jargon, recommendations, and assumptions based on our past experiences. The patient, though, is facing this for the first time. They need more information, reassurance, and time to process the change in their life and view of themselves.

As physicians, we need to recognize our own feelings and limitations but also the power and influence that we have over our own patients. When we cannot cure someone, we can often feel as if we have failed. Yet many diseases cannot be cured. We only fail if we do not provide the best care for our patients or if we pull away from them as they struggle with their illness. Patients rely on us to be their guides on the rocky journey of illness and, hopefully, recovery. If we decide that we cannot cure them and pull away because we have no additional treatment to offer, we leave them stranded at the scariest part of an unknown trail. Our presence and promise to help them navigate their illness can be extremely important in the doctor-patient relationship. Patients validate this truth. While they value a physician’s medical knowledge and expertise, patients actually appreciate humanistic characteristics more. In scoring of what makes a good doctor, being scientifically proficient came in third after sensitivity to emotion, which included listening skills, and positive personality traits [10]. We need to consider that “Communication is the most common ‘procedure’ in medicine” [11, p. e1441]. So how can we develop these skills?

2.1 Active listening, clues, and agendas

There are three elements to consider when thinking about communication—informativeness, interpersonal skills, and partnership building [11]. What we are trying to do is connect with our patients, provide the information that they need to understand their illness and treatment options, and work to form a partnership to navigate the terrain of the illness and treatment. When we think about this relationship it is helpful to remember that “there are two types of patient needs to be addressed during the medical interview: cognitive (serving the need to know and understand) and affective (serving the emotional need to feel known and understood)” [11, p. e1442].

When engaging with patients we need to actively listen, which is much more than just staying quiet and paying attention. Although as we already discussed, physicians even have difficulty with the staying quiet part—interrupting their patients early in the discussion. As ([12], p. 1053) points out, “Active listening is a difficult discipline. It requires intense concentration and attention to everything the person is conveying, both verbally and nonverbally.” We begin to realize how challenging this can be when we consider how we often participate in conversations. Typically, individuals half-listen to a story and spend much of their mental energy thinking about what they are going to say when it is their turn. Or we find ourselves thinking about what we need to do next or reconsider a past decision. We are there in the conversation but not completely there. We also are not usually considering what the other person is not saying. We do not watch for signs of discomfort, which can indicate when someone is holding back uncomfortable information. Yet those are the exact conversations that we need to be having with our patients.

For example, Robertson [12], defines some roadblocks that can occur when we are trying to actively listen. One is judging or evaluating the other person’s perspective. Our role is not to decide if the complaint is as detrimental as a patient is describing. Maybe it would not be so devastating for us but we need to listen to their experience. We often jump in and offer solutions before we completely understand our patient’s complaints. If the conversation is uncomfortable, we try to divert the discussion or reassure the patient, which may seem like a good thing but if it is done too early, it prevents the patient from fully being able to discuss their concerns. Active listening includes demonstrating our attentiveness through our body language and facial expressions, which can be harder in the current time with the need for masks in the healthcare setting. We need to consider our questions. Yes or no questions often become the staple of physicians’ language as we work to zero in on positives or negatives in the review of symptoms. This, though, hampers the patient in telling their story. What is more helpful in active listening is “door openers,” such as encouraging the patient to tell you more about the problem, how it is affecting their life, anything that they have tried to solve the issue, and what they are most concerned about [12]. One reason to explore these questions is that “most patients who experience illness symptoms develop an explanatory model” ([13], p. 222). Even before they enter our offices, patients have started to think about their symptoms and have often developed an explanation based on their frame of reference. For example, if they have a persistent cough and know someone who passed away from lung cancer that can be one of their main worries, or in current times, they may fear having COVID-19. If we do not discover what they are truly worried about, our reassurances will not be believable.

The authors [13] analyzed recorded interviews between students and patients and followed up with patients to understand potential clues being offered in the interviews. These clues if pursued provided improved insight into a patient’s concerns. The clues often included an expression of feeling—such as describing being bothered or worried; attributing a concern to someone else, such as a family member, which allowed the patient to slip the uncomfortable issue into the conversation, or vividly describing the symptoms. Another avenue for patients to convey clues was to offer their own explanations about a symptom. This made it clear that they had been thinking a lot about the issue and were trying to figure things out. They were looking for a physician to either confirm or deny their worries. Clues are fairly common in medical interviews. Clues occur in 52% of primary care visits, and 53% of surgical visits with a mean number of clues of 2.6 per visit in primary care and 1.9 clues per visit in surgery [14]. Over half of our patients are offering clues and if we follow up on them, we can have a more meaningful and impactful conversation and connection. Often physicians do not follow up on the clues or utilize active listening because there is a fear that something will be brought up that will then extend the visit. However there is evidence that the opposite occurs—following up on clues not only does not make visits longer, but in some cases, it can shorten visits. In primary care visits that included at least one clue, visits were longer when the clue was not followed up on as compared with visits in which physicians demonstrated a positive response to the clue—for primary care mean visit time was 20.1 minutes if the clue was not followed versus 17.6 minutes if a positive response was given; for surgery, visits were 14 minutes when the clue was not followed up as compared to 12.5 minutes when it was [14]. In another study, patients who were asked open-ended questions took only 16 additional seconds to present their symptoms (27.1 seconds versus 11.3 seconds) than patients who were asked closed questions [15]. In ref. ([13], p. 226) we are reminded that “while the use of active listening carries certain challenges, identifying the patient’s real concerns usually results in a new level of understanding of the patient, increased satisfaction for both patient and physician, and improved medical management.”

Visits typically focus on the physician’s agenda—to identify the illness through a biomedical lens and offer treatment. For example, Levenstein et al. [16] describe the importance of incorporating not just the physician’s agenda in the session but also the agenda of the patient. Discovering the patient’s agenda is not always as simple as asking what they want to talk about that day but also watching for the clues described above that hint at deeper concerns. The physician’s agenda is to be able to understand and explain the patient’s illness by identifying and categorizing the patient’s disease. The patient’s agenda is to come to an understanding of the illness but to also be able to express his/her feelings, expectations, and fears. Visits are more successful when both agendas are addressed and any conflict or different expectations are negotiated and discussed. This can be challenging, at times, especially if symptoms cannot be easily explained or answered. Both parties may feel frustrated but the patient will feel abandoned if the doctor does not delve into the emotions and concerns related to the illness. If a physician does not explore or consider the patient’s narrative, increased conflicts can occur [17]. In these situations, especially if the physician feels that the patient is not agreeing to the recommendation, they tend to become more coercive rather than interactive. “Physicians must always take care to avoid considering their narratives as ‘the truth’ and the patient’s narrative as ‘fiction’ if it happens (as it often does) to disagree with that of the physician” ([17], p. 14). One way to obtain the patient’s narrative is through active listening. We then need to respect their narrative.

2.2 Nonverbal communication

One way that respect is conveyed is through our nonverbal communication. It is vital to ensure that we do not shut the conversation down before it has even had a chance to get started. This can happen through initial nonverbal signs. When I was in the hospital after having delivered my second child, I remember when the pediatrician came to visit me. He barely entered the room, stood with his arms crossed in front of him, and asked if I had any questions. I did not—this was my second child and my husband was a pediatrician—but even if I had wanted to ask any questions, his stance stopped the conversation before it could even begin. There was clearly no invitation to express concerns or ask questions.

Nonverbal communication includes eye contact, head nods and gestures, position, and tone of voice [18]. Eye gaze, in particular, demonstrates engagement and listening to the speaker [15]. Consider how you are placing yourself in the room—is the computer between you and the patient? Are you staring at the screen instead of making eye contact with the patient? If you need to turn away from the patient to check something on the computer, clarifying the action can be helpful in maintaining the connection—such as identifying that you need to check a lab value or medication to help further understand the patient’s story [15]. Too often we interact more with the computer rather than with the patient. Sitting versus standing makes patients feel that the physician is more caring and compassionate and has spent more time with the patient [18]. Often the visit is not longer if the physician sits, but it can feel that way [19]. The physician is there in the moment with the patient and not standing with one foot out of the door.

Nonverbal immediacy (being clearly present and connected in the session) improves patient satisfaction [20]. Through our facial expressions and body stance, we need to be present and not dismissive. We need to communicate engagement and interest, not detachment and annoyance. If a patient has a worry, we need to acknowledge it and not just dismiss it. If a patient feels that their concerns were seen as frivolous or annoying, they will not want to ask us or other physicians about them for fear of getting the same response. Our communication strategies, especially the way we nonverbally express our reactions, can have huge impacts on the doctor-patient relationship.

2.3 Dealing with emotions/biases

Another tool that helps with the relationship is the physician’s emotional regulation [20]. Patients want their physicians emotionally engaged but with regulated emotions so that they do not overwhelm the interview. We need to be aware of our emotions so that they do not leak out in nonverbal responses or prompt us to lose our professional composure with our patients. We need to be aware of our biases so that we do not unintentionally (or intentionally) alienate our patients. We often define patients as “difficult” when they engender too much negative emotion in us. “For example, the angry patient can irritate a doctor so intensely that he will become angry in return, avoid contact with the patient, or even occasionally refuse treatment” ([21], p. 1045). Certainly physicians need to keep themselves safe when dealing with angry patients but tools can help defuse some of the emotion. These include trying to understand what is fueling the negative feelings. I have worked with patients whose anger stemmed from feeling a loss of control from the illnesses and proposed treatments. When we worked to understand their concerns, their anger lessened, they were able to engage in the treatment, and eventually become more motivated to pursue recovery. Another tool, “My go to technique that I train folks on is learning to soften their tone and the volume. While it does not always work, generally people want to hear what is being said (and when we talk softly, it often adds an air of importance to what we are saying). More often than not the person that is escalated will match your tone…” [D. Schwartz, personal communication, August 16, 2021].

At times we can recognize a patient’s emotions by the emotions that they generate in us. When we start to feel angry, it can be a clue that the patient is experiencing that emotion as well. There are ways to try to connect with a patient’s emotions. Reflection can be useful—telling the patient what you are noticing. For example, if you sense the patient is feeling sad, stating that fact can help deepen the conversation. This can be more effective than asking a question. If a patient is sad, asking them why can lead to the response that they do not know why. We often do not know why we feel a certain way. But making the observation that someone is sad and reflecting back as they expand on their thoughts can help the patient and physician get to a deeper place of understanding [21]. It is important to legitimize their feelings and provide support. It can be helpful to provide respect for what the patient is doing well—such as coming in to talk about the symptoms or any other tools they have used to try and help themselves. This provides a perspective for the patient that they can be successful as they continue to navigate the situation [21].

Other challenges and increased emotions can come from misunderstandings. Physicians tend to underestimate patients’ pain and overestimate patient education [22]. Evidence has been shown that physician bias can enter into this with physicians sometimes underestimating the pain of African-American patients in particular [23]. If we leave a patient in pain, clearly this is going to interfere with our relationship. If we overestimate a patient’s level of understanding that can leave them feeling confused and with unanswered questions. These challenges can compound each other. One study demonstrated that physicians’ styles of communication were affected by their perceptions of patients. Physicians were more patient-centered, less contentious, and more positive with patients whom the physicians felt to be better communicators [24]. In this study, physicians were more contentious with black patients than with white or Hispanic patients. Within this study, we can see some of the systemic racism in healthcare that has been identified in the United States. We also see that the patients who probably need clearer communication from the physician and more engagement in the process are those who are on the receiving end of more negative interactions.

Another challenge is when patients and physicians have very different thoughts or perceptions of what might be happening but do not fully discuss their beliefs. In this situation, assumptions can be made. For example, this can occur when a physician believes that part of the patient’s symptoms is related to an emotional component. For many illnesses, a psychological component can exacerbate the physical symptoms. Examples can be gastrointestinal issues, such as irritable bowel syndrome or headaches to name just a couple of commonly occurring conditions. If the physician suggests that it might be helpful to see a therapist or psychiatrist, often the patient hears that the physician believes this is all in their mind. They feel like their symptoms are not being taken seriously. Other issues maybe when there are clear stressors in the patient’s life but they seem to be discounting them—describing that they are not stressed at all. Individuals with lower back pain discussed how validation of the extent of their suffering helped with the doctor-patient connection [25]. One concern of patients is that their suffering will not be recognized or it will be invalidated. If that happens, communication hits a wall. Patients will not want to share further experiences or ask additional questions because they worry that they will not be believed. In ref. [26] there is evidence of other barriers, such as the patient introducing unexpected resistance to a suggestion or evidence of verbal-nonverbal incongruity. In this case, the patient can verbally say that they agree with the doctor, but their nonverbal language may suggest that they do not accept the doctor’s explanation and won’t follow up.

So how can we navigate some of these barriers? One example of how a physician can navigate the challenge of unexplained illness or pain is to explain that with our current tools, he cannot find something physically wrong at this time. That does not mean something is not there. We have seen symptoms that were previously dismissed now being understood as Chronic Fatigue Syndrome. Just because we cannot figure out what is wrong now, does not mean there is not a physical issue. One way to approach this is to acknowledge the patient’s physical complaints and discuss plans to work on them but consider how to move forward if the physical symptoms continue but cannot be more clearly diagnosed. The physician can acknowledge that the physical symptoms may not be completely resolved in the near future, or maybe ever. At that point, the discussion can turn to how the stress of these symptoms is affecting the individual. The discussion of therapy can be used to empower the patient to find additional ways to handle their symptoms while you both continue to look for a source or a cure. If they are able to decrease some of their stress, that might help with the physical illnesses.

Sometimes good communication means finding a way to ally with your patient, merge your goals and suggest options in ways that will be agreeable to him or her. It is important to separate the problem from your patient. For example, if we work with patients who struggle with fatigue, we try numerous ways to try improve the symptoms and yet they are still fatigued, it can be frustrating to both the patient and physician. If in the middle of that frustration, the doctor blurts out, “I cannot find anything wrong physically. It must be stress. You need to see a therapist.” How will the patient feel? We need to recognize that our frustration is not with the patient, it is with the fact that we cannot seem to fix the problem. We cannot find an easy cause or explanation and so it feels frustrating. The patient, though, will hear this as a rejection. They will feel blamed for their symptoms. They will feel not believed. We need to remember that both the patient and physician can feel frustrated when a cure cannot be easily found. We are not frustrated with each other; we are frustrated with the situation. This brings us back to how to approach this conversation—with compassion and empathy. “I can tell that it is frustrating to feel so tired all the time. I am also frustrated that we cannot find a clear reason and solution. We will keep trying to understand what is happening. In the meantime, it might be helpful for us to consider some additional tools. Sometimes when individuals are struggling with physical symptoms for so long, they can feel stressed by the situation. This can make the fatigue worse. Also being so tired can sometimes make it hard to keep up with everything that you want to be doing in life. Talking about how to cope with that frustration can be helpful. So while we work together on the physical side, how about if I get you the name of a therapist who can help you navigate this challenge?” It might take a few times of suggesting the option to get buy in. But it is important to communicate belief in your patient’s views, support for their struggles, and work to align with them to find additional tools to improve their health.

2.4 Understanding personality disorders, boundary issues, and trauma-informed care

Patients who struggle with personality disorders can often elicit intense emotions. This can make communicating effectively with them in medical settings difficult. At times, healthcare workers might try to avoid these individuals because of the difficult emotional encounters. Unfortunately, that can often spiral the difficulties. If a patient is scared and angry because of his illness or the lack of answers and yells at individuals who approach him, staff will try to avoid him as much as possible. It is only natural—none of us like getting yelled at or dealing with anger. Yet when we distance ourselves from this patient, he becomes even more angry and scared and we get stuck in this cycle. Ways to try to intervene are similar to some of the techniques above. We need to stay calm, we need to provide information in clear and simple terms. We can let the individual know that his anger is making it hard for people to do their jobs. If he is trying to get answers, yelling at staff is not going to help with that goal.

For patients who struggle with borderline personality disorder (BPD), they can often get stuck in anxiety and sadness [27]. Individuals with BPD often have their anger triggered by anxiety. This can be important to remember as physicians. If we are dealing with someone who is extremely angry, we need to consider if they are reacting that way because of overwhelming fear. How can we defuse the anger? As above, through using a calm voice, ensuring that they and everyone are safe, and suggesting that maybe part of why they are so angry is that this situation feels overwhelming and scary. Try to help them talk through their fears and the next steps. Reassure them that the staff will work to help support them through this challenging time. Helping to decrease their intense emotions can help defuse the situation and also decrease their intense feelings. For example, Nisselle [28] reminds us to not think of these individuals as difficult patients but to consider more than it is a difficult relationship or discussion. This makes the difficulty more at the moment and allows us to think about how we can get the discussion back on track. If we label the patient as difficult then we do not see hope for any change.

There are certain techniques that can help individuals who struggle with personality disorders. Reference [29] provides a thoughtful and excellent guide. He looks at the three types of personality disorders and offers suggestions on how to deal with them. Cluster A, which includes paranoid, schizoid, or schizotypal, are individuals who are often not comfortable with interpersonal interactions, they stay by themselves and are often fearful, believing others are out to harm them. Some of the tools that we use to try and create a close relationship, will often make these patients even more uncomfortable. Instead, we need to recognize that it was difficult for them to even reach out for help. We need to maintain a professional demeanor, use simple language, and not challenge any odd beliefs, but work to help them navigate the medical tests that are necessary for their treatment. For Cluster B, which includes antisocial, borderline, histrionic, and narcissistic, we need to recognize that our emotions will often be stirred up by these individuals. At times, we will feel manipulated. Often they will either manipulate us into feeling their intense emotions or try to use our emotions to get what they want from the situation. For some, this manipulation is intentional (typically antisocial individuals) and at other times, it is unintentional but is a byproduct of their personality disorder. For individuals with borderline personality disorder, they feel things so intensely that they can engender those feelings in us. Sometimes the first way to handle the situation is to identify what we are feeling and question whether that is how they are feeling in the moment—angry, scared, overwhelmed. Again with these patients, it is important to create a professional distance, recognize the need, and set limits as appropriate. Limits will be tested and it is always important to consider, are we setting limits to help maintain our professional relationship with the patient or as a punishment because we have felt taken advantage of, either through requests or through the emotions that they have stirred up. It can help when considering requests or limits to thinking about whether you would do this for all of your patients. Often individuals struggling with these personality disorders will feel entitled and will push for requests that are not reasonable in the situation. Limits need to be set because they will help maintain the professional nature of the relationship and allow you to treat the patient. They should not be set in a moment of anger or frustration. Individuals with these personality disorders are probably the most difficult to work with and engender intense feelings in healthcare professionals. It is important to recognize that their behaviors are part of their personality—they cannot often recognize them or change them. It can help to breathe, to take a step back if needed, and to think through your responses. Individuals with a borderline personality disorder often evidence black and white thinking. Things or people are either all good or all bad. If you are the best doctor ever, appreciate it but do not get lulled into that belief. Keep a professional distance and work to provide care to that patient as you would to any other client. At some point, in their eyes, you may be the worst doctor ever because you have disappointed them in some way. You might not even know how this happened. Again, keep a professional distance and work to provide the care you would give to any other patient. None of us are all good or all bad even if we are made to feel that at the moment. Cluster C includes avoidant, dependent, and obsessive-compulsive individuals. For these patients, performing complete history and physicals so that you can provide reassurance and also complete explanations can help with reassuring them.

Individuals who struggle with personality disorders can often try to influence a closer relationship with a physician. It is important for physicians to recognize and set clear boundaries with patients. This does not mean that we have to be distant and uncaring but we need to recognize our role within the situation. “Boundaries define the expected and accepted psychological and social distance between practitioners and patients” ([30], p. 2569). This includes recognizing that we are their physicians and not their friends. It can relate to self-disclosure. Self-disclosure can be helpful if it is used to benefit the patient but not if it is to help unburden the physician. While many times self-disclosure helps with communication—to perhaps encourage screening tests by sharing a similar situation—there are times that self-disclosure is used more to unburden the physician rather than to help the patient [31].

We need to recognize and consider how our actions might be perceived by our patients and others—are we giving more time to one patient, willing to see them in a different location, or stepping over boundaries, which will muddy the doctor-patient relationship and confuse or harm our patient? [30] Recognizing the importance of boundaries can be especially important when working with individuals who have, perhaps, experienced trauma and is part of the recognized technique of performing trauma-informed care (TIC) [32]. For individuals who have experienced past trauma, their boundaries have been violated. Often it can be that a person that they trusted harmed them through emotional, physical, or sexual abuse. This can make it hard for individuals to trust. When considering boundaries and TIC, it can be helpful to consider how to provide a place of safety both physically, a private room where the person feels free to talk, and emotionally, helping the individual understand what is going to happen next in the encounter so that know where they are going to be touched and why [32]. Part of understanding boundaries is understanding the power differential between patients and physicians, especially as our patients are sitting there in a hospital gown, and not taking advantage of the power that we as physicians hold over our patients. Sometimes this power allows us to invade a patient’s space even when we do not realize that we are doing it. We need to be aware of the situation, such as are we allowing the patient to stay as covered as possible while we perform the procedure or understand that our touch might trigger past traumas.

Sometimes in interviews physicians hold back from perceived boundaries that actually limit the connection with a patient and the level of understanding of their issues. In a fourth-year elective in the Department of Humanities, I worked with a number of medical students. In a standardized case, they had to work with a patient who was being seen for hypertension but had a number of beliefs and a past history that affected her willingness to pursue treatment. Within the case, if the student asked questions in a way that made the patient feel comfortable, she would provide more backstory. If they did not pick up on any of the cues that she provided, she did not provide that part of the history. In discussing the encounter with the students after the session, many noticed the cues by the patient that indicated that there was more to the story—looking anxious and fidgeting. When we discussed why they had not pursued these cues and asked the patient more about her past social history or concerns, they related that they did not want to be seen as too “nosy.” We need to respect the patient’s boundaries and discomfort but we also need to be able to open the space and ask the necessary questions. If patients do not want to provide their history, they will usually say that they do not want to talk about it. That is a clear boundary. If, though, they are providing hints through their actions that there is more to the story, they are often waiting for us to give them the space to discuss their concerns. If we do not provide that space or seem willing to talk about a topic, then they will feel that they shouldn’t bring it up. We need to be “nosy” at times. We need to ask if there are other concerns. Is there more that they are worried about or something that they are finding hard to discuss? A calm and interesting persona lets our patients know that we are not asking these personal questions just to satisfy our curiosity but we are asking them because they seem to be on the patient’s minds and affecting their lives.

2.5 Suggestions

While each of us has our own communication style and comfort within interpersonal relationships, there are some tools that can be taught to help improve communication when you are working with patients. First is to keep in mind that we may need to let the patient tell their story of why they are there. Instead of interrupting in the first few seconds, as physicians tend to do, let the patient describe their concerns. In typically within 2 minutes or so, they will have told you their story [33]. One can see that this will not extend the interview by much time, but it will allow you to understand what is really on your patient’s mind. Patients follow the style of their doctors. If the doctors frame questions very narrowly from the beginning of the encounter, then patients try to follow those unspoken guidelines and offer limited answers. I often advise trainees to consider the interview as a funnel—start broadly and ask questions that give the patient the space to tell their story. Then at the end, you can narrow your questions to obtain more specific details if they are needed. When conducting the session, it can help to record facts about the patient’s personal story—if they have kids or are heading on a vacation. Using that in the next visit can help to foster the relationship. It can help with patient satisfaction [33]. Individuals feel seen as a person, with interests and a life outside of the illness.

Mnemonics and models are offered below that focus on how to ensure that active listening and other skills are included in the interview. While there are other models available, these offer ways for physicians to consider their interviews and if they are listening to and engaging their patients. Using skills from these models can help physicians improve their communication and, thereby, their relationships with their patients.

For example, Nisselle [28] talks about the 4 ‘E’s’. Did you engage the patient? Did you start the conversation off in a collaborative tone? The next E is empathy. Does your patient feel seen and heard? Do you truly understand the level of their suffering? Third is education. Has the patient been given enough information to understand your recommendations? The final E asks whether you have enlisted your patient. Have you worked to align your goals to that of your patient so that you are on the same team—that your patient understands your plan and is willing to try it. Education and enlisting are so important but often not included to a necessary extent. For example, when discussing discharge plans, physicians believed that 89% of patients understood the potential side effects of their medications, but only 57% of patients reported that they understood the risks. Physicians believed that 95% of patients understood when to resume normal activities, while only 58% of patients reported that they understood [34]. How can we enlist patients to complete the treatment plan if they do not understand it?

In ref. [35], a great mnemonic is presented to help physicians recognize the individual natures that both we and our patients bring to our encounters. A stands for I Am. This focuses on meaning—what is important in the patient’s life? How are you finding meaning in your work with the patient? B stands for I belong. This focuses on the sense of community—for the patient, whom can they turn to for support; for the physician, what resources are available, are there others that can help in this care? C stands for I can. For the patients, they want to know if they have the capacity to get better—what can they do to affect the outcome; for physicians, we want to consider what we can do to positively influence this patient’s health. D stands for I dread. This is what the patient is worried about. As a physician, our worry is about whether we can make our patients better. E stands for I exist. This is different than the existence of the individual person but focuses more on the existence of the physical body—the patient wants to know what is wrong. The physician needs to consider the biomedical explanation of the illness and what care to provide. This prompt can take us from what is important in our work—the overall recognition of the person, which has to be our paramount concern to the level of determining what is wrong. We need to work from the global recognition of the person as a whole before we dive into treating what is wrong on a cellular level. Too often physicians work from the opposite direction—they focus on the specific illness and ignore the person who is struggling with the symptoms, emotions, and influences of the illness on their life.

One study in Southeast Asia looked at the Greet-Invite-Discuss technique and found that it led to a more partnership-oriented and culturally sensitive communication in primary care settings when physicians were working with patients with chronic illness [36]. The technique outlines: Greet—initiate and maintain a “familial” relationship with patients; Invite—explore the patient’s story; Discuss—use negotiation and shared decision-making tools to develop a plan [37]. When using the framework, improved blood pressure and blood glucose control were demonstrated as compared to a more doctor-centered, list of questions approach [36]. As we see with these techniques, patients feel respected, seen as a whole person, and listened to. When considering the relationship with the patient, I often tell students to speak with the individual as they would want someone to talk with one of their family members. This does not mean stepping over boundaries as we discussed earlier in this chapter but treating the individual with respect, seeing them as a person who is important to others, and understanding them as someone’s child, mother/father, brother/sister, cousin, wife/husband or friend. How would you want your loved one treated by a physician? That is the way we need to talk with our patients.

The Four Habits Model describes an interrelated set of skills, which include investing at the beginning of the interview, eliciting the patient’s perspective, demonstrating empathy, and investing in the end [38]. “The goals of the Four Habits are to establish rapport and build trust rapidly, facilitate the effective exchange of information, demonstrate caring and concern, and increase the likelihood of adherence and positive health outcomes” ([38], p. 79). In the initial habit, the authors focus on creating a welcoming connection so that the patient knows that they have our full interest and attention (remember active listening?). They recommend using open-ended questions to elicit the patient’s concerns and recommend that you plan out the visit with the patient. This last step allows both the physician and patient to include items that will be important to the agenda of the day’s visit [38]. Within the use of open-ended questions, they offer ideas of how to get more information about any concern—using silence, nonverbal signs of interest, and asking the patient to “tell me more” about any concern that they have raised. This allows the physician to understand the patient’s underlying concerns and what brought them in. The physician might have their agenda for the visit but if they do not address the patient’s actual concerns, the patient will leave the visit feeling dissatisfied and not heard. The reader can see how these skills flow together because the second habit is to elicit the patient’s perspective. It has already been started in the beginning as the physician creates rapport with the patient and starts asking open-ended questions about the reason for the visit. In this habit, as the physician gets more of the story, he/she works to understand how the concern impacts the different areas of the patient’s life. They work to understand what the patient has already tried and what worries they have about the symptom. By understanding the hidden worries, perhaps worries they have already linked to the symptom, the physician and patient can more clearly discuss the symptoms. Any reassurance will be more believable if the patient’s actual fear has been discussed—for example, if they have a headache and are worried about a brain tumor, getting the fear out into the conversation can allow the physician to address it more clearly. The third habit is demonstrating empathy, which of course cannot happen in just one moment but needs to be present within the entire interview. This is why the authors discuss how these skills are interconnected. By demonstrating empathy, the physician conveys a willingness to understand a patient’s emotions related to their concerns. Often physicians side-step this because feelings are difficult. It is easier to focus on trying to identify the cause of pain rather than address the emotional pain of the patient—the fear of what is causing the pain, the sadness at the loss of activity related to the pain, and the anger at being the victim of pain. The fourth habit is investing, in the end, to try and develop a plan that the patient is comfortable with to help ensure adherence to the plan [38]. The physician can develop the best plan possible but if the patient is not on board with the diagnosis, recommendations, and next steps, the chance of them complying is very limited. These four habits help physicians and patients work together to improve communication and the overall visit and partnership.

An expanded four habits model improves work with patients who struggle with emotional distress [39]. The authors work with the four habits model but focus on skills to allow for more in-depth exploration of the emotional concerns of the patient. This means being sensitive to and willing to explore the patient’s emotions and being empathic to these emotions. Exploring more fully the patient’s perspective and understanding so that both patient and physician have improved insight. The physician assesses the patient’s resources and strengths and uses this information to empower the patient and focuses on strategies for coping with the illness. Both the Four Habits and Expanded Four Habits are patient and relationship centered. Rather than using a checklist of symptoms, the interaction is a focused on patient’s fears based on their history. Yes, checklists help us identify what the illness might be and the next steps but if we do not establish a good relationship with our patients, there is a good chance that they will not follow through with the recommendations.

The expanded four habits model uses skills from ref. [40], which identified six skills that are important in patient-centered interviews and care. The first is exploring a patient’s emotions—this can occur by staying silent and giving the person more space to talk. Or it can happen by reiterating a patient’s described emotion—You have felt overwhelmed?—or by asking them to tell you more. [41] describes silence as a particularly useful tool, which can be easily introduced into a session but can feel overwhelming to the physician. The author describes that typically when a patient stops talking, the physician jumps in faster than even a second. Sometimes the patient might not even be able to complete their thought before the physician jumps in. Waiting even 10 seconds after the patient has stopped speaking can lead to vital information. Patients will continue talking to fill the space and in these moments can express what is really on their minds. Ten seconds of silence will feel long but that small space of quiet can allow the patient a chance to express concerns. The second skill is to respond empathetically to the patient—this can happen by acknowledging that something must be very hard for them or expressing pleasure in something good that has happened to them. The third skill is exploring the patient’s perspective to see what thoughts they might have as to what is causing or contributing to the problem. They might turn it back on you and say that you are the doctor. But if they have been living with this symptom, they might have their own theory or worry. This skill is to work to understand that. The fourth skill is to help provide insight, perhaps looking at vicious cycles, such as when the patient becomes anxious about the pain, it can cause an increase in the pain, which continues the cycle. The fifth skill is to explore resources of the patient, what have they done that has helped, to help identify their strengths, and to explore outside supports. The sixth skill looks at improving coping. In this skill, the physician builds on the strategies that the patient has been using, which have been, at least, somewhat successful.

In all of these models, physicians are encouraged to invest at the beginning of the interview by developing rapport and eliciting the patient’s concerns. Within these frameworks, there is a focus on obtaining the patient’s perspective—working to understand how the current concerns are affecting his/her life. [41] discusses that paraphrasing what the patient said can help us understand their perspective and help with clarification if we have misunderstood something. You can use the phrase, “So what I hear you saying is…” and see if you have heard the patient correctly. Within these interviews, it is important to demonstrate empathy, both verbally and nonverbally. As we have discussed in this chapter, nonverbal behaviors can have a huge impact on an interview. Physicians need to also invest in the end, making sure that the patient understands and agrees with the treatment recommendations. The skills involved in these frameworks include being sensitive and exploring the patient’s emotions; exploring the patient’s perspective and understanding; assessing the patient’s resources and strengths; and promoting empowerment by focusing on coping. These methods may seem overwhelming but they can improve communication. Our goals must include understanding our patients’ concerns and engaging them in the treatment plan.

The ALERT Model works to connect with questions that are asked to explore how patients feel about their healthcare and providers. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) in the United States “…assess how well the physician listened carefully to the patient, how often the physician explained things understandably, how often the physician showed respect for what the patient said, and how often the physician spent enough time with the patient” ([42], p. 70). The ALERT Model works to remind physicians about these assessments and how to ensure that these techniques are part of their interview style. The model stands for: Always Listen carefully; Explain things understandably; Respect what the patient says; Manage Time perception [42].

While these models explain what a physician needs to do in the sessions, it is important that the physician stays in the moment. If the physician focuses on whether he/she is following the exact guidelines and using the precise phrasing of questions, then they are missing the point of these suggestions. The guidelines offered through these models and in this chapter are to help the physician be more present and engaged with the patient. It is important to connect at the moment and not be distracted by wondering if you have, for example, paraphrased enough or managed time perceptions.

Within these models, managing time perception relates to time within the visit. Even simple things, such as apologizing if you have kept a patient waiting, can help at the moment to improve the relationship and improve communication. Patients often feel as if a visit is longer if the doctor has sat down with them and maintained good eye contact. Glancing at his watch or looking hurried can cause the patient to feel as if not much time was spent with them. Time perceptions are also important to remember related to how doctors and patients define time in general. In ref. [43] the author describes that physicians who have become patients start to understand some of these differences a little more clearly. Physicians, once they had been patients understand that when anxiety or uncertainty hangs over a patient’s head, it can affect the sense of time—lengthening it as one suffers and struggles with the unknown. Time is no longer an objective measurement but subjectively feels much longer and more unsettling. Helping patients understand and navigate the process can be an important part of the relationship so that the patient feels supported and understood.

3. Conclusion

When we practice medicine, we need to consider whether we are treating the illness or the patient. This chapter focused primarily on the goal of listening to our patients, working to hear their unique stories, and being open to the different emotions or fears that may accompany illness. Many of these suggestions can help physicians develop deeper connections with our patients. Those connections can help our patients feel more understood and cared for. They can help us find more satisfaction in our work. That satisfaction can benefit us all—patients and physicians. We need to not only be good physicians but also work to be great physicians. We need to treat the patient, not just the illness.

Conflict of interest

The author declares no conflict of interest.

Thank yours

I must thank all the patients, students, and physicians whom I have worked with. They have shared stories of both good and challenging communications. It is through them that I have developed more of an appreciation for the “art” of medicine and the strength of interpersonal relationships between physicians and their patients.