Is there evidence that communication skills affect outcomes of care?

Many studies over the last 25 years have demonstrated that communication skills can make a difference in all of the following objective measurements of medical care – it is not just subjective.

Process of the interview

  • The longer the doctor waits before interrupting at the beginning of the interview, the more likely she is to discover the full spread of issues that the patient wants to discuss and the less likely will it be that new complaints arise at the end of the interview (Beckman and Frankel 1984, Joos et at 1996)
  • At the beginning of the interview, interrupters include echoing and facilitation
  • The use of open rather than closed questions and the use of attentive listening leads to greater disclosure of patients’ significant concerns, increased talkativeness and expression of emotions (Cox 1989, Maguire et al1996, Wissow et al 1994). Similarly the use of the open to closed cone yields more relevant information, There is the loss of significant (often negative) information without the use of closed questions.
  • Asking “what worries you about this problem” is not as effective a question as “what concerns you about this problem” in discovering unrecognised concerns (Bass and Cohen 1982).
  • The more questions patients are allowed to ask of the doctor, the more information they obtain but with increased negative affect (Tuckett et al1985).

Patient satisfaction (much evidence, a weak measure of outcome)

  • Greater “patient-centredness” in the interview leads to greater patient satisfaction (Stewart 1984, Arborelius and Bromberg 1992)
  • Discovering and acknowledging patients’ expectations improves patient satisfaction (Korsch et a11968, Eisenthal and Lazare 1976, Eisenthal et al. 1990)
  • Physician non-verbal communication (eye contact, posture, nods, distance, communication of emotion through face and voice) is positively related to patient satisfaction (DiMatteo et al 1986, Weinberger et al 1981, Larsen and Smith 1981)
  • Patient satisfaction is directly related to the amount of information that patients perceive they have been given by their doctors (Hall et al1988), highly consistent finding.

Patient recall and understanding

  • •Asking patients to repeat in their own words what they understand of the information they have just been given increases their retention of that information by 30% (61 to 83% of information retained) (Bertakis 1977)
  • There is a decreased understanding of the information given if the patient’s and doctor’s explanatory frameworks are at odds and if this is not discovered and addressed during the interview (Tuckett et al 1985).
  • The patient recall is increased by categorisation, signposting, summarising, repetition, clarity and use of diagrams (Ley 1988).

Adherence

  • Patients who are viewed as partners, informed of treatment rationales and helped in understanding their disease are more adherent to plans made (Schulman 1979).
  • Doctors can increase adherence to treatment regimes by explicitly asking patients about knowledge, beliefs concerns and attitudes to their own Illness (Inui et al, 1976, Maiman et al 1958)
  • Discovering patients’ expectations leads to greater patient adherence to plans made whether or not those expectations are met by the doctor (Eisenthal and Lazare 1976 Elsenthat et al 1990)

Outcome

Symptom resolution

  • A one-year prospective study of Canadian family medicine in 272 patients investigating the natural history of chronic headache in primary care found that resolution of symptoms of chronic headache is more related to the patient’s feeling that they were able to discuss their headache and problems filly at the initial visit with their doctor than to the diagnosis (except organic), investigation, prescription or referral (The Headache Study Group 1986) (3.4 times more likely compared to 3.2 times for organic v. Non-organic)
  • Recovery speed in URTI related to the discussion of concerns about illness ta than investigation, treatment, examination or culture) (Brody and Miller 1988)
  • Training doctors in problem-defining and emotion-handling skills not only lead to improvements in lit detection of psychosocial problems but also to a reduction in patients’ emotional distress up to six months later (Roter et al 1995)

Physiological outcome

  • Giving the patient the opportunity to discuss their health concerns rather than simply answer closed questions leads to better control of hypertension (Ortli et al 1987).
  • Innui 1976 also showed better BP control in the same context.
  • Decreased need for analgesia alter myocardial infarction is related to information giving and discussion with the patient (Mumford et al 1982)
  • Providing an atmosphere in which the patient is involved in choices if any are available, leads to less anxiety and depression after breast cancer surgery (Fallowfield et al 1990)
  • RCT evidence that patients who are coached in asking questions of and negotiating with their doctor not only obtain more information and report better health but actually achieve better BP control in hypertension and improved blood sugar control in diabetes. (Kaplan et al 1989, Reel et al 1991)
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