When asked if they would like to be involved in decisions about their health care, approximately 9 of 10 US patients say they want to know all of their options. But far fewer people said they were offered options than wanted to discuss them, and, by offering a range of options, health professionals are only beginning a process of shared understanding. At its simplest, shared understanding may involve a one-off binary choice (eg, take an antibiotic or have a surgical procedure), but often it involves a dialogue that must be maintained through the complexities of chronic or comorbid illnesses.
Technically excellent care is an important goal, but quality is represented by something more than this. The top factors influencing whether people believe they have experienced quality care are good interpersonal skills from clinicians and associated staff, including communication and empathy; easy access to care, including convenient appointments with a familiar clinician; and involvement in care processes, including participation in decisions and self-care support. The art of the office visit (consultation) lies in creating a collaboration in which both the clinician and the patient are aware of the limitations and uncertainties of the clinical evidence but seek to make the most of the opportunity to align their goals and values.
Shared understanding is more than information. How can we move from the science of a technically focused exchange of information to the art of mutual understanding?
The Zen of the Office Visit
Many consultation models emerged in the 1970s from work led by researchers in family medicine and psychiatry. They differ in task or behavior orientation, and their focus has been on either the physician or the patient. The models provide maps for clinicians to navigate their way through consultations while picking up on important nuances, such as hesitation or the telling glance.
Communication skills training entered most undergraduate curricula about 20 years ago. The basics of teaching any skill involve instruction, demonstration, repeated practice, and supportive feedback. Repeated cycles of this interaction help fine-tune the skills and move the learner from conscious incompetence (“I have no idea how to discuss anticoagulation to prevent stroke in someone with atrial fibrillation.”) to unconscious competence (“I’ve had training and feedback on how to communicate about anticoagulation to prevent stroke. I have done it a number of times. I know the technical data so well now that I don’t need to think consciously about it; I can now focus on the preferences and needs of this individual.”).
Many physicians now learn and practice communication skills as undergraduates or residents but obtain no further education, skill development, or feedback after they begin independent practice. In an annual patient survey in the United Kingdom that included the question “Were you involved as much as you wanted to be in decisions about your care and treatment?” the percentage who answered yes has stayed, not surprisingly, just above 50% since 2002.
Mutual understanding requires high-level skills. When sharing technical information, clinicians usually prefer to inform of certainty almost all the time, even when guidelines express uncertainty. Patients translate reduced probability that a disease would progress into their condition has been definitely treated. Physicians rarely have accurate expectations of benefits or harms, usually underestimating harms and overestimating benefits.
Promoting the Science of Kindness
Physicians can develop the “science of kindness” in several ways: explicitly acknowledging uncertainty and the limitations of information, showing compassion for the patient’s need to make decisions based on limited supply of certainty, and considering clinician and patient perspectives to facilitate shared decision making.
The skills to enable this “science” should be a core clinical topic in a lifelong curriculum of learning for all medical specialties. Such a curriculum begins with basic undergraduate instruction and demonstration and continues through postgraduate training. Practice and supportive feedback are required to promote progression from novice to expert communicator, returning to the same topic but reaching higher levels each time. Opportunities to hone physician-patient interaction may seem limited, but more can be created. Clinicians can observe one another, videotaping can provide insights, and actors playing patients are widely used in for learning and assessment. Virtual and augmented reality may soon contribute to learning through repeated practice. As Aristotle observed, “We are what we repeatedly do.”
Physicians can create an opening by asking patients to share something about themselves. If physicians learn more about their patients, they may be able to help patients make better-fitting decisions. It is often helpful to ask patients about their understanding of their illness. Do they think of it as a punishment? As inevitable? Do they believe it can be cured or treated? Can they see the parts of it they may be able to control?
Such conversations often follow from a discussion about the goals of care. To ensure that the agenda is the patient’s, the physician should clarify, “What would a good day look like for you?” and “What are your fears for the future?” Teaching and learning can improve the communication about risks and benefits. In many consultations, shared understanding and decisions can be achieved without discussion of numerical probabilities. Decision aids—increasingly available—may help in specific circumstances.
Gently encouraging patients to learn about health in general and their illness in particular is time well spent. More information sources are available than clinicians can monitor, but physicians can direct patients to reputable sources and help interpret the information found. Sometimes knowing where to find the evidence of risks and benefits and communicating the evidence in several ways (finding ?1 kind of framing appropriate for that patient) can be helpful. For example, a patient with a 10-year cardiovascular risk of 30% might gain a better understanding of benefit from the following description: “If there were 100 people like you and all 100 took a statin for 10 years, then there would be 12 fewer people who had a heart attack or stroke” (assuming a relative risk with statins of 0.6). Such an approach uses natural frequencies to express risks and probabilities. An alternate method is to use numbers needed to treat: “If we were to treat people like you with a statin for 10 years, then for every 8 or 9 people treated there would be 1 fewer heart attack or stroke.”
Physicians can also reflect on their experiences. Discussion groups that focus on the therapeutic relationship between physician and patient with the objective of increasing the understanding of the patient’s problems and not finding solutions originated in the 1950s from the work of English psychiatrist Michael Balint. Such discussion groups can help physicians understand what they bring to the interaction and how they can better listen to and discern their patients’ needs at that point.
Finally, professional development plans for physicians should include making a commitment to improving shared understanding with patients. Without good communication, health care is wasteful at best and dangerous at worst. With good communication, patient complaints are fewer. Professional satisfaction also increases as skills improve. Most important, patients do better.
Conclusions
Even with more and better data and improved descriptions of risks and benefits, the evidence does not constitute all the information required for appropriate decision making. Good decisions rest on the quality of the conversation between clinician and patient. The inherent complexity of such dialogues means that striving for the “perfect” consultation will result in professional frustration. Instead, lifelong commitment to improving the context and content of patient-clinician communication, along with a will to partner with the patient, increases the proportion of decisions based on true shared understanding.
