By Robert Provenzano, MD, FACP

I was flattered when asked by the editors of aakpRENALIFE to do an article on communicating efficiently with patients. As a physician, I am avoidably bias, and the more I thought about this topic and tried to relate it to my own practice, the more I focused on those patients who feel I am an excellent communicator and those (thankfully a few) who believe I am not.

What I will try to do in this article is help define issues that will help break down barriers that exist when communicating with your physician. However, there will be several ground rules that must be accepted as you read this article.

Ground Rules

• Doctors are human and therefore imperfect.

• Patients are human and therefore imperfect.

• There are very few bad patients.

• There are very few bad doctors.

• The unifying theme behind the first four ground rules is we are all human and therefore subject to all the stresses that humans are exposed to in the 21st century.

So, that said, let’s focus on communication.

Communication

In general, communicating effectively is a highly developed skill. It is developed over time and improves with practice. No one is born as an effective communicator. During a physicians training, effective communication skills are commonly focused on in critical way. Despite this, there will be some physicians who will be better communicators than others.

The communication skills of patients also need to be developed. Younger patients are often less skilled at effective communication than older, more mature, experienced patients.

Remember, effective communication is a process where information is mutually exchanged from patient to physician and from physician to patient. This is important to realize so expectations on the part of both individuals participating in communication can be realistic.

Physician’s Communication Goals

A physician often has a defined goal when communicating with a patient. He/she is often interested in telling certain medical information that is necessary for the patient to appreciate their current health status. Part of this information is to educate the patient as it pertains to their healthcare, and other information is for informational purposes only.

Additionally, the physician is often trying to engage the patient to better understand their social situation. Information about your family, spouse, children, employment, work-related issues, and insurance related issues are often discussed at this time. A physician may also communicate with you in an attempt to gain your confidence, to convince you that he/she is knowledgeable about nephrology in general.

Another important aspect of physician communication is attempting to gain information related to a disease state. These questions are often very well defined, goal directed and pointed. For example, a physician may question you about shortness of breath, whether it is related to pulmonary status or a cardiac condition, etc.

Patient’s Communication Goals

This can be similar to or totally apposed to those of the physician. If you are a new patient, you may be trying to determine the physician’s level of competence. This is best done by asking pointed questions rather than withholding information to determine whether or not the physician “guesses right.” Patients will also be attempting to determine how they are doing as it pertains to their end-stage renal disease (ESRD) or to other co-morbid conditions they may have. They will be seeking information on medications, side effects and/or drug interactions. Often, patients will be interested in addressing insurance coverage and other payment issues.

They will often focus greatly on expectations of care: “how am I expected to do doctor,” “what is my life expectancy,” etc. One area of questioning that often goes unasked deals with patient fear. It is not uncommon for patients to expire in the dialysis unit or following a hospitalization. This rarely gets discussed with other patients unless specific questions are asked. Although detailed medical information cannot be discussed due to Health Information Privacy Act (HIPA) regulations, many issues resulting in fear on the part of the patient can be addressed and help rid those fears.

Communication Barriers

These barriers can be real or imaginary. I will attempt to list major barriers and focus on the actual impact they have on a doctor-patient relationship.

1. Time

The average hemodialysis patient is treated 12 to 13 times per month. Generally speaking, physicians will round a minimum of once a month, often sending physician extenders on a weekly basis, or your physician may round more often. It is rare that the physician will round less than once a month, except where geography makes more frequent visits impossible. Physicians tend to be very busy and often are pulled in several directions at once. They often allocate a specific amount of time to spend in the dialysis unit. It is difficult to predict what patients will require a great deal of time, due to their healthcare needs, and who will not. Therefore, the patient is often guessing at time allocations.

I am not making an excuse for physicians, rather I am attempting to help patients understand why physicians will be drawn to patients who are sicker or have specific needs, rather than those who tend to be stable and have less needs. You should ask what your physician’s rounding schedule is. Come prepared with a list of questions to make the visit most efficient. You should invite the physician to spend a few moments with you. You should be sensitive to his/her time, particularly if you know there are unstable patients in the facility who require much more of his time, but notify him/her that at their next visit you would like an opportunity to discuss your case.

2. Language

We do know that nephrology has an overrepresentation of international medical graduates. Although language barriers are a potential problem, you should specifically address them with your doctor if you have trouble understanding him/her. You should ask that they speak slowly, concisely and in a way that you can understand. You should be treated with respect and dignity when asking. If language continues to be a major barrier despite your best efforts, you should tell the medical director of your facility to see if interpreter services are available. The corollary to this is many patients may not speak English. If that is the case, it is important that patients bring their interpreter to the dialysis unit on a very frequent basis. If the patient becomes unstable, it will be necessary for someone to be able to communicate with them. They should tell the doctor a specific day that the interpreter will be there if there are any questions concerning healthcare so the visit is efficient for both parties.

3. Emotion

Emotions often run high for the patient and physician. Patients are often very angry with their diagnosis. They may feel the healthcare system has somehow failed them. It is only human to try to funnel anger toward a healthcare worker who is often the doctor. The nephrologist may have stepped on a potential landmine when an angry patient is trying to lash out at someone. There is no simple solution to this. I have dealt with many patients who are angry because they did not know or understand that they had “weak” kidneys and would eventually require dialysis. Try to work with your nephrologist. Try to be understanding that he/she is attempting to help you and will assemble a team of individuals to do so. It is important to be honest and forthright but to funnel that anger constructively. It is very bad if your anger is manifest by “writing off” all healthcare professionals. Becoming disengaged in your healthcare does not serve you!

Physicians may also be angry. The ESRD program is one of the most heavily government-regulated programs, mandating frequency of visits and quality outcomes. Although many feel these are positive steps, they may not be shared by your physician and, therefore, if your physician seems angry it is within your preview to question them as to why and what you can do to help. This is often disarming and will open a route of communication for both of you.

4. Cultural Differences

There will come times in which cultural differences interfere with effective communication. This article is too general to list them all. Every attempt should be made by the patient and physician to work through these barriers, either by inviting interpreters, cultural leaders (Imams, Rabbis, Priests, etc.) to the dialysis units to bridge communication barriers from cultural differences.

5. Racial Bias

It is possible, although thankfully extremely rare, that the race of a patient or physician may be a communication barrier. Ethics sworn by physicians should prevent this from existing. However, if you believe it exists, try to keep a level head and communicate your concerns either directly to the physician or, as often easier, indirectly through a social worker or the nursing personnel so it can be addressed. It is often necessary to address this through the medical director.

Again, rarely a case may arise where a patient is unhappy or uncomfortable with the race of their doctor. As patients are not bound by any oath, Hippocratic or otherwise, they should immediately discuss their discomfort with the physician and the physician should find another nephrologist who will accept care of the patient. One would hope these occurrences would remain rare and eventually become a footnote in history.

Tools for Effective Communication

One of the most effective tools in aiding communication between patients and doctors can be initiated upon their first meeting. There should be an introduction so the patient and physician “get to know each other.” One wants to make good eye contact, shake hands, and talk about issues that both feel will be important to develop the relationship. At that time, the patient will quickly discover if they are comfortable with that doctor or not, as will the physician. You, the patient, may ask the physician what he/she is most comfortable with as far as communication. Offer to write one or two very important questions at each visit that you may want the physician to answer. Do not exceed this minimum number as the physician may view you as trying to “monopolize his/her time.” There may be times you have no questions – that’s fine! Tell your physician your doing great; wish him or her a good day as you would with anybody. Do not feel obligated to ask questions if you don’t have any. Often, some questions can be directed to other members of the nephrology team.

Engage the physician in a respectful way and expect to be treated with respect in return, other than in an accusatory manner. All of us are stressed at times; directing accusations is a very poor way to open a discussion. Don’t use that as the message you want to send. Come prepared by writing down your question if at all possible.

If the questions you have are of a personal nature, ask the physician if you can schedule a time in his/her office to address these concerns and bring a family member along if possible. If the physician seems rushed, ask them whether or not there is a better time to talk. It may be that his/her office is running behind he/she had unexpected emergencies or other issues of a personal nature impacting his/her time. Your sensitivity will help build a relationship between you and your physician.

Conclusion

Communication is the key to improved outcomes and patient and physician satisfaction. It takes work on all of our parts. Approach it in a mature and open-minded manner. Patients should not be intimidated by their physician, nor should physicians fear hostility of patients. It is only through open communication, basic manners and mutual appreciation of the goals of communication, that we can all work together to break down artificial barriers interfering with effective communication.

I would like to thank the previous work in this area by George Aronoff, MD; George Porter, MD; and John Newmann, PhD, MPH, who assisted in the preparation of this manuscript.

Robert Provenzano, MD, FACP, is chief of nephrology at St. John Hospital and Medical Center in Detroit. He is also president of the Renal Physicians Association.

This article originally appeared in the November 2005 issue of aakpRENALIFE, Vol. 21, No. 3.

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