“What We've Got Here Is a Failure to Communicate”

Communication is critical and plays an important, but often overlooked role in visits to physicians. Not only is good patient– physician communication necessary for most medical care, it also serves several functions including building trust and establishing the patient–physician relationship. Inadequate communication is associated with worse patient satisfaction, worse trust, more complaints and malpractice claims. Moreover, the communicative features of the consultation (e.g., information exchange, shared decision-making) can influence health care outcomes. There is a recognized need to improve communication in medical encounters because patients who have difficulty communicating with their physicians are less involved in the visit, less informed, and less satisfied with care. Effective communication by both patients and physicians can produce better patient self-management, adherence to treatment recommendations, and follow-up, thereby lessening the burden of disease. In the context of chronic disease, the passive transfer of educational information alone is less likely to result in improved outcomes when compared with goal setting, shared decision-making, and other collaborative approaches. These communicative processes require both active communication behaviors by the patient and patient-centered communication by the physician. Focusing solely on physician communication skills may be insufficient. Efforts to improve patient–physician communication should recognize that communication is a two-way street. Because of norms of communication, patients who use active communication behaviors (e.g., ask questions) are more likely to influence their physicians’ communication (e.g., get answers). In turn, physicians who are more supportive and relationshipcentered can influence patients to become more active participants in consultations. Thus communication is a process of mutual influence. Improving this dynamic process between patients and physicians is challenging. For physicians, communication should not be limited to medical tasks and should also include patient-centered communication behaviors that: (i) assess and address their patients’ knowledge and goals; (ii) provide empathy and support; (iii) engender trust and partnership; and (iv) verify understanding. For patients it is not enough to answer physicians’ questions; patients need to overcome passivity and use active participatory communication behaviors (e.g., ask questions, communicate concerns, make requests) to gain conversational control and influence the interaction with their physicians. Passive patients may not point out their needs, concerns, and beliefs. Passive communication limits the physicians’ ability to identify and meet the patients’ needs for information, support, and reassurance, to make accurate diagnoses, and to formulate the most appropriate and personalized treatment plans. Research supports this argument. For example, when patients assume a passive or non-participatory role in the interaction, physicians obtain less information for making appropriate treatment decisions and patients are less committed and less satisfied with those recommendations. Furthermore, the evidence supports that active participatory communication behaviors are associated with positive post-consultation outcomes including adherence to and recall of physicians’ recommendations, patient satisfaction, improved functional status, and even improved biomedical and physiological outcomes. Despite the recognized importance of patients and physicians making a positive effort in communication, a number of barriers exist. These barriers include differences in patient and physician race, ethnicity, gender, language, culture and many others. Communication may be most difficult when multiple barriers are present, and efforts to inform and understand one another may become frustrating for both parties involved. For example, communication difficulty disproportionately affects racial minorities. Black patients are less likely to use active communication behaviors (e.g. ask questions) in consultations with physicians when compared with white patients. The problem is potentially intensified because of a communicative cycle that perpetuates passivity where physicians provide less information to patients, and in turn patients do little to prompt physicians for more information. 6,7 Although it is often said that “patients and physicians do not speak the same language,” few studies have actually examined the effect of language on health care outcomes. In this issue, Fernandez et al., report results of a study evaluating associations of language barriers with glycemic control among limited English proficient (LEP) patients with type 2 diabetes mellitus. Language barriers were assessed according to patients’ ratings of how well their personal physicians spoke their language. Among Latinos with language concordant interactions there This work was supported in part by grant # PPO 08-402 from the VA Health Services Research and Development Service. The views expressed in the article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.