Essential Elements in Good Practitioner-Patient Communication

Essential Elements in Good Practitioner-Patient Communication

In May 1999, 21 leaders of medical education and professional organizations wrote guidelines defining the essential elements of good communication in any type of medical encounter. These guidelines are called the “Kalamazoo Consensus Statement on the Essential Elements of Communication in Medical Encounters.” [1] While written primarily by and for MDs, it is my experience that these guidelines are also appropriate for acupuncturists and professional practitioners of Chinese medicine. Therefore, I would like to present these essentials for acupuncture students and practitioners alike. These essentials are grouped under seven headings that take the practitioner and patient from the beginning to the end of any encounter.

1. Opening the discussion

A. Allow the patient to complete his or her own opening statement

I usually begin by asking what has brought the patient to see me that day. Then I sit back and allow them to talk for up to 3-5 minutes without interrupting if they so wish. I want to hear the patient’s reason for seeking my help, and I want to hear that reason in their own voice.

B. Elicit the patient’s full set of concerns

When the patient has finished their opening recital, I ask if those are all the issues of concern or if there may be other things they would like my help and/or advice on. It’s better to get the big picture as early on in the encounter as possible.

C. Establish and maintain a personal connection

I typically try to find something in common with each patient. This may be where they live or where they originally came from, their occupation or hobbies, or something about their family. What I’m looking for is a way to connect on a personal as opposed to a purely medical level. For instance, if a person is from Missouri, I might tell them about the time I found a box turtle in Missouri which my kid brought home to Colorado, or I might ask if they had ever visited Merrimac Caverns where Jesse James hid out.

2. Gathering information

Of course, acupuncturists and professional practitioners of Chinese medicine use the four examinations for gathering information, and questioning is one of those four methods. However, here we are talking about how one questions and how one listens, not necessarily what questions to ask. Those should have been learned as an undergraduate in acupuncture school.

A. Use open-ended and close-ended questions appropriately

An open-ended question might be something like, “How’s your digestion?” or, “How’s your sleep?” A close-ended question is, “How many bowel movements do you have each day?” It is common to ask open-ended questions first which are then followed up by close-ended questions nailing down the specifics. Typically, open-ended questions do not give you enough information on which to base a pattern discrimination. An open-ended question is, “How’s your energy?” If the answer is, “I guess ok,” you haven’t really learned anything very useful. However, if you ask, “Are you fatigued?” then the answer should be either yes or no, and from there you can find out how fatigued and when fatigued.

B. Structure, clarify, and summarize information

I refer to clarifying as reframing. For instance, if a patient says that he or she is constipated, it is important to clarify exactly what the patient means by this. Does he or she mean they do not have a bowel movement every day or that they do have bowel movements daily but that the stools are difficult to expel? Or do they mean that the stools are dark-colored and hard in consistency? The reason I use the word “reframing” is because I am typically reframing the patient’s answer from a layperson’s answer to an answer using specifically Chinese medical signs and symptoms.

Structuring means telling the patient what the options are for answering questions. For instance, phlegm may be either thick or thin, white, yellow, or green, scanty or profuse. Summarization means the boil down and recapitulate the essential information you have gleaned from a less tight, more rambling answer. For example, the patient may tell you a number of different things about their bowel movements. At the end, you may then ask,“So in other words, what you mean is that you have one bowel movement per day which is a light yellow in color, slightly soft, and somewhat burning around the anus?” This both confirms the patient’s answer and also summarizes the key diagnostic points.

C. Actively listen using verbal and non-verbal techniques

There is active and passive listening. Active listening using verbal techniques means such things as saying, “Yes,” “Um-hm,” “I understand,” “Right,” etc. It also means repeating what has just been heard. “So what I just heard was that... Is that correct?” Non-verbal techniques of active listening mean using eye contact, nodding one’s head in agreement, and making other facial and bodily expressions in response to what has been heard. Patients often complain that their health care provider has not listened to them or “heard” them. Verbal and non-verbal techniques of active listening help instill in the patient the feeling that they have been listened to and have been heard.

3. Understanding the patient’s perspective

People generally dislike being treated in “cooky-cutter” or “one size fits all” fashion. Each person feels unique and wants to be recognized and treated as a unique human being. the following pieces of advice help practitioners see and hear each patient as a unique individual as well as part of a larger bi-directional matrix. This leads to personalized, holistic, comprehensive health care.

A. Explore contextual factors

Contextual factors include such things as family, culture, gender, age, socioeconomic status, and the patient’s spirituality. These factors all affect our health and well-being and need to be included in any estimation of a person’s total situation. For instance, in some cultures, some women loss status at menopause, while other women in other cultures gain status. Medical anthropologists have shown that such factors affect the incidence, severity, and duration of menopausal complaints.

B. Explore beliefs, concerns, and expectations about health and illness

The mind is hugely powerful and has a large impact on our health and our ability to recuperate when we are ill. Placebo is generally accorded a 40% role in all recuperation. Therefore, in order to assess a patient’s prognosis and ability to heal, it is necessary to understand their beliefs about their situation. For instance, if a patient is convinced they are going to get and are consumed by their fear of life-threatening breast cancer, then a double preventive mastectomy might make sense.

C. Acknowledge and respond to patients’ ideas, feelings, and values

A practitioner does not have to agree or endorse every one of a patient’s ideas, feelings, or values. Sometimes patients have some pretty far-out ideas. However, it is important to always acknowledge these ideas and beliefs. “I can understand that you may not want to do this or that, but, according to my training and in my experience, I really think this is the best thing for you.” If you immediately dismiss a patient’s belief or idea as nonsensical, foolish, or ill-conceived, you have belittled that patient. If that idea or belief is strongly held, you have probably just lost that patient. It’s possible that adults can agree to disagree as long as both have listened to and really heard each other.

4. Sharing information

A. Use language the patient can understand

While the average person reads at the sixth grade level, they probably speak at a somewhat higher level. Nevertheless, it is important to use easily understandable words with patients without being seen to be talking down to them. It takes a lot of skill and ingenuity sometimes to explain Chinese medical concepts in English to the general public, but it can be done if one makes this a priority. Chinese medicine is based on an everyday vision of reality which describes the body and its ills in terms that everyone can understand, such as hot and cold, wet and dry, too much and too little. My experience is that most people can understand such explanations. Other points to keep in mind are that Anglo-Saxon words are usually easier to understand than Greek or Latin words and that one should keep technical jargon to a minimum.

B. Check for understanding

Sometimes it’s obvious from a person’s verbal and non-verbal cues that they understand us. Other times it may be hard to tell if the person listening has understood what we’ve just said. In both cases, it is almost always appropriate to ask if the person has understood and, if there’s any question about that, to ask them to tell you what they think they heard. We should not assume that other people have understood us just because we have understood ourselves. Therefore, it’s important to check that we have made ourselves clear to our listener.

C. Encourage questions

Some people have to be encouraged to ask questions, especially when talking with an “expert.” Therefore, it’s always a good idea to ask patients from time to time if they have any questions about anything you’ve said. Typically, after I’ve explained a patient’s pattern discrimination, I ask if they have any questions about that or what else they’d like to know about their situation. Some shy people have to be encouraged more than once to ask questions.

5. Reaching agreement on problems and plans

By the end of each patient encounter, there should be an agreement on the patient’s problem and a plan to deal with that problem. That agreement should be explicit, not just tacit or implicit. Willingness and ability to follow through on such agreements can be improved by using the following three techniques.

A. Encourage the patient to participate in decisions as much as possible

Studies have shown that the patients who typically do best are those who actively participate in their own treatment. It is my personal experience that it is easier to elicit “buy-in” and “follow-through” when patients feel like they have participated in the choice of treatment plans. Therefore, patients should be encouraged to participate in making treatment decisions to the limits of their abilities. However, that does not mean the patient should run the show. The practitioner needs to structure their relationship with the patient in such a way that the patient can have in-put in places where their in-put is appropriate. Ultimately, the practitioner is responsible for the treatment they provide. That is why the word “participate” has been used and not the word “dictate.”

B. Check the patient’s willingness and ability to follow the treatment plan

There’s no sense in setting out an elaborate treatment plan if the patient cannot or will not follow it. Some patients will not take pills; others will not take decoctions. Some patients will not accept needles, while others hate the smell of moxa. Before reaching a conclusion on a particular treatment plan, it is important to check with the patient to make sure that he or she is both willing and capable of following that plan. I have wasted time more than once explaining to vegetarian patients how to make meat bone broths and soups only to learn that the patient refuses to eat any meat. If I had checked first that they do eat meat, I may have saved myself some time and effort. I have also had patient’s bring back bags of Chinese herbal formulas which they refused to take because they contained animal parts and they were vegetarian. Again, a simple question first would have found this out.

C. Identify and enlist resources and supports

If a patient says they can’t or won’t do a particular treatment, find out if this objection is absolute or negotiable. For instance, a patient may say that they cannot come in the following day for treatment because they don’t have use of a car. Perhaps there’s a municipal agency that can give them a ride or maybe there’s a friend they could ask for a lift. There’s more than one way to skin a cat and, similarly, there’s usually a way to work around objections and impediments to treatment. Another example is the patient who says he or she cannot take her herbs because they make them sick to their stomach. In that case, perhaps taking them with meals avoids that adverse reaction.

6. Providing closure

As one comes toward the end of each patient encounter, it’s important to provide a sense of closure for both parties. A sense of closure reinforces the “reason” and “rightness” of the encounter. The encounter becomes like a play with a beginning, middle, and end, and everything feels of a piece, whole and complete. There are several things that can be done at this time to help provide such closure.

A. Ask whether the patient has other issues or concerns

Toward the end of each patient encounter, ask if the patient has any last issues or concerns. If you’ve done a good job with the foregoing communication skills, there often is nothing further. However, by the patient’s recognizing there’s nothing further they need to ask about or discuss, a sense of completeness is instilled and reinforced in the patient.

B. Summarize and affirm agreement with the plan of action

“So we’re agreed that you are going to do X, Y, and Z, right?” This further emphasizes the main points of the action plan and confirms one more time that the patient is going to follow through as directed.

C. Discuss follow-up

This means discussing the next visit or call as well as any “what if” scenarios. At the end of every single patient encounter, there should be a plan for the patient’s next encounter, whether that be a live, in-office visit or a phone call. In addition, this is when any last minute advice may be given about what to do in the case of any adverse reactions or side effects. “If you happen to feel nauseous, be sure to call me.” Or, “If you feel nauseous, drink some ginger tea. If that doesn’t help, then call me. In any case, I’m going to want to see you next week. Please make an appointment with the front office staff.”

In this information age, we are all becoming more and more sophisticated about communication. Good communication is an art. It is also part of a successful, low risk practice. While acupuncturists and professional practitioners of Chinese medicine tend, as a group, to be more than usually kind and compassionate, every one can increase and improve their communication skills. Attention to these essential elements of communication in medical encounters is one way to improve those skills.