Establishing Rapport

Robert E. Rakel

Chapter contents

Respect

147

Nonverbal Communication

149

Patient Satisfaction

147

Paralanguage

149

Patient Dissatisfaction

148

Hidden or Masked Communication and Patients' Expectations

158

Listening Well

158

Communication

148

Verbal Communication

148

Rapport comes from the French en rapport, which means "in harmony with." Rapport is most easily established during the patient's first visit, and achieving rapport enhances the likelihood that the patient will comply with the treatment plan. When rapport has been established, patients are more likely to forgive a less than perfect experience or an unexpected poor clinical outcome.

Even the most knowledgeable and skilled physician will have limited effectiveness if he or she is unable to develop rapport with patients. Unfortunately, rapport is one of those intangibles that is more than the sum of its parts. Rapport is not analyzed easily within any one body of knowledge. The basis of rapport, however, is the development of communication skills that instill in patients a sense of confidence and trust by conveying sincerity and an interest in their care and well-being. The patient's satisfaction and compliance with the physician's instructions (both measures of rapport) depend on the ability of the physician to communicate understanding, compassion, and genuine interest in the patient and to display a thorough approach to solving the patient's problems. Patient satisfaction also is related to the physician's efforts in educating patients about the disease process and motivating them to participate in their treatment.

Failure of communication between physician and patient also can affect the outcome of treatment, often as seriously as an error in treatment. More complaints against physicians result from a breakdown of the caring aspect of the doctor-patient relationship than from the technical quality of treatment.

Most complaints against physicians—and those that too frequently lead to legal action—are the result of a lack of communication between physician and patient. The potential for a serious problem always exists when a patient is inadequately informed regarding a diagnostic procedure, treatment, prognosis, or anticipated cost. The misunderstandings that result cause unnecessary expense and grief for both parties.

Similarly, the worries that result from distorted information can jeopardize the physician-patient relationship. When a patient is discussed on hospital rounds or with a colleague in the office, take care that the discussion is not within the patient's hearing distance or within that of other patients. Patients overhearing the conversation may believe the comments apply to them, or they may know the patient involved and relay the information in a distorted manner. Fragments of such conversations, overheard by the patient or others, are too easily taken out of context and can become the focus of fearful fantasies that only serve to increase uneasiness and apprehension.

Compassion, interest, and thoroughness are essential components of successful patient care. These features traditionally have been embodied in the term bedside manner, which also connotes qualities of concern, kindness, friendliness, wit, and cheerfulness, all of which result in an atmosphere of trust and confidence between physician and patient. The physician with the best bedside manner may be the one who makes no special effort to communicate these feelings but acts in a concerned, natural, and comfortable manner.

Oliver Wendell Holmes said that to be effective, the physician should "speak softly, be well-dressed, have quiet ways and have eyes that do not wander" (1883, p. 388). Lack of eye contact may be interpreted as a lack of concern. A good first impression is certainly a great help in establishing rapport. You do not get a second chance to create a first impression. The physician should approach the patient in an assured, confident (but not cocky or arrogant) manner and present a personal appearance that is acceptable to the patient. Empathetic frankness and honesty are important factors in instilling confidence and trust.

Personal appearance is a significant part of nonverbal communication. Patients consider house staff who wear white coats with conventional street clothes as more competent than those who wear scrub suits. If white coats are worn, the patient sees only the collar, tie, and shoes, and it is therefore important to keep these items neat.

Posture is also important in conveying an image of confidence and competence. Standing erect, moving briskly with head up and stomach in, is better than slouching. Energetic people seldom slump; they sit upright and appear alert. A listless or lethargic appearance can be interpreted as lack of concern.

Before entering the examining room or hospital room to see a patient, review the record briefly and become familiar with the patient's name and its proper pronunciation. If the pronunciation is unusual or difficult, place phonetic markings on the chart as a reminder for future use. Repeat the patient's name when first given it to confirm the pronunciation, and then use the name twice in the first minute to help it register. Review the medical record for particular aspects of the previous visit that should be remembered and commented on, such as the illness treated at that time, family conditions, or other problems. Patients will believe that the well-informed physician is truly interested in them. Additional courtesy, such as opening the door and assisting patients with their coats (especially elderly patients), shows a consideration that aids in establishing and maintaining rapport.

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