Verbal Communication

Much of the communication process in the clinical interview centers on verbal interchange. Symptoms, past medical history, family medical history, and psychosocial data are transmitted primarily by verbal means. The chief complaint is extremely important because it explains why patients believe they need the physician's help.

Patients who do not mention a concern and who withhold requests are less satisfied with their care and experience less improvement in their symptoms. Bell and colleagues (2001) found that 9% of patients had one or more unvoiced desires and were most hesitant to ask their physician for referrals and for physical therapy. These patients were also less likely to trust their physician. This is an important reason to be sensitive to subtle clues that the patient may be suppressing something important to them. What the patient does not say may be as important as what the patient says.

"Slips of the tongue" or major areas of omission (e.g., a married person who never mentions a spouse) may signify problem areas that, when explored, help establish the interviewer as a perceptive person who understands the underlying issues. The interviewer constantly must consider, "Why is the patient telling me that?" Even simple, casual remarks may be the patient's way of broaching issues of great concern; the man who says, "Oh, by the way, a friend of mine has been having some chest pain when he walks a lot. Do you think that sounds serious?" may actually be talking about his own concern that he is unable to face directly. A child may be brought to the office with a trivial problem so that the mother has a chance to discuss with the physician something that is troubling her; the child is a calling card, signaling the need to open the communication channel. The physician who is sensitive to these subtle clues and encourages the patient to discuss what is actually troublesome will find that the rapport established allows future interviews to be much more open and direct.

Hand-on-the-Doorknob Syndrome

The patient's parting phrase is sometimes a clue to the primary reason for the visit, or it may reflect another issue of great concern that is emotionally threatening and could not be voiced until adequate courage was summoned at the moment of departure. It sometimes surfaces as a last, desperate attempt to communicate because, with a hand on door, escape is readily accessible if the physician's reaction is unfavorable. Reasons for this hidden communication by the patient are important and must be recognized and addressed. Because of fear of rejection or humiliation, the patient may test the physician with minor complaints before mentioning the real reason for the visit (Quill, 1989). The physician must be alert to any unusual behavior during an interview (e.g., slips of the tongue, unexpected responses, overenthusiastic denials) and should search further for the underlying reason for the visit when a patient presents with a trivial complaint that appears inappropriate. It is a good practice to ask the patient routinely at the end of a visit, "Is there anything we have not covered, or anything else you would like to ask me?"

Patients with a fear of cancer, for example, often are unable to voice their concern to the physician. Instead, they present with somatic complaints or contrived reasons that necessitate a complete examination. They are hopeful that the examination will allay their fears without it being necessary to express them openly. A female patient presenting for a complete physical examination actually may be concerned over the possibility of a carcinoma of the breast, which her elder sister might have had at the same age or for which a friend recently had surgery. Such situations emphasize the need for a complete family history and a discussion of any patient concerns in an effort to allow these feelings to surface. Attention then should be paid to alleviating the anxiety. Apprehension regarding cancer is widespread, and the only cure for this fear often is a therapeutic conversation with the physician.

Physicians in private practice who have established rapport during an ongoing relationship with patients communicate more easily than do physicians seeing a patient for the first time in an emergency department (ED). Korsch and Negrete (1972) showed that ED physicians did more talking than the patients, although their perception was just the opposite. This was attributed to interaction with unfamiliar patients by house staff in a setting where the stress level is high and the orientation therapeutic. However, Arntson and Philipsborn (1982) found that physicians in private practice for 26 years who knew their patients and saw them in a low-stress situation for diagnosis or health maintenance also talked more than the patients (twice as long). One difference in the two settings was a strong, reciprocal affective relationship between physician and patient in the private office. If either made an affective statement, the other would respond similarly, whereas in the ED, patients expressed twice as many affective statements as did the physicians.

Vocabulary

The use of appropriate vocabulary assists in establishing rapport by ensuring easy and accurate communication. Phrasing questions in simple language appropriate to the patient's level of understanding and avoidance of medical jargon help establish a sense of working together. The patient's cultural background and educational level should be considered, and the physician should avoid using slang or a contrived accent, because the patient will detect the artificiality and consider this patronizing.

Patients prefer to be enlightened, and they demand maximum insight into their care. It is best to start all explanations at a basic level and proceed only as rapidly as the patient's understanding permits. An analysis of 1057 audio-taped patient interviews with 59 primary care physicians and 65 surgeons showed that in 9 of 10 cases, patients did not receive good explanations of proposed treatments or tests (Braddock et al., 1999).

Medical terminology should be avoided unless it is familiar to the patient. For example, some patients have interpreted "lumbar puncture" to mean "an operation to drain the lungs." No longer does the physician gain a therapeutic advantage by writing prescriptions in Latin or impressing the patient with medical terms.

Metaphors can be harmful and are often used without the physician being aware of the negative connotation, unknowingly raising the patient's anxiety level. Attempts to coerce a patient into having surgery with phrases such as "you are living on borrowed time" may cause anxiety and increase postoperative morbidity (Bedell et al., 2004).

Physicians should be sure of what patients mean to convey by their word selection and make certain they are operating at a common level of understanding. When the patient says he or she "drinks a little," inquire further to clarify "a little." If the patient "spits up blood," determine whether it is truly spitting or really vomiting. A major barrier to accurate interpersonal communication is the tendency of people to react to a statement from their own points of view, rather than attempting to interpret it from the speaker's vantage point. If a question exists regarding the clarity of the interpretation, it is best to repeat it to the speaker's satisfaction. Contract negotiators have found that when parties in a dispute realize that they are being understood and each party sees how the situation appears to the other, there is less need to exaggerate and act defensively. Korsch and Negrete (1972) found that some of the longest interviews between physician and patient were caused by failures in communication; they had to spend considerable time trying to "get on the same wavelength." An analysis of the conversations revealed that less than 5% of the physician's conversation was personal or friendly in nature, and that although most of the physicians believed that they had been friendly, fewer than half of patients had this impression.

Getting to Know Anxiety

Getting to Know Anxiety

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