Patients with alcohol or other substance misuse disorders often have complex presentations of addictive behaviors and medical comorbidities, making these patients uniquely challenging to treat. Because of the complex nature of these patients, communication failures can lead to missed therapeutic opportunities. Given the shift in healthcare to a more patient-centered approach and positive association between high-quality communication with a health care provider and improved patient outcomes, it is essential to acknowledge and assess factors that generate dissonance between the patient and the physician. Furthermore, providers can better manage interventions, referrals for treatment, and assessments of patients’ willingness to change with more effective communication tools.
Verbal Communication Barriers
Word choice when asking questions or explaining a diagnosis or treatment plan may contribute to discord within the doctor-patient relationship. Physicians may use complicated medical terms that patients may not understand. Patients come from different socioeconomic backgrounds and therefore have different literacy levels. If confronted with a word or phrase not understood, patients will often avoid the embarrassment of not knowing the medical term by affirming to a yes or no response, which can be unreliable during interviews.
Studies have shown that physicians do not disclose enough pertinent information to patients, which can impact a patient’s involvement in their care. Proper communication allows patients to be more knowledgeable about their prognosis and to be more proactive in seeking assistance.
Non-verbal language, including facial language, body posture, and paralanguage, influence a patient’s perception of a physician. For example, a patient may interpret a negative facial expression and a raised voice as feelings of annoyance.
Medical school, residency, fellowships, and long careers often take both an emotional and physical toll on physicians. As a result, their ability to empathize with patients decreases over time and may often lead to the belittling of patients. Physicians have their predisposed biases of patients which arise from their values and experiences. These stigmas can negatively affect a patient’s quality of care. For example, addicted patients usually are on some type of medication to suppress their addictive habits. If these patients request more medication to alleviate their symptoms, they may be labeled as “drug-seeking” and would not receive proper treatment or even a smaller dosage.
Patients may hesitate to provide accurate information because they feel distressed or distrust. They may worry about the violation of their security or autonomy. They may feel anxious about being in an unfamiliar environment such as a hospital, clinic, or outpatient facility and worry about the next steps in their medical intervention. It is helpful to remember that patients sense negativity and disinterest with both facial expressions and nonverbal gestures.
Angry, irritated, or combative patients may not only lead to frustration but also biased treatment. It is crucial to identify the reason for the patient’s frustration. Educational background, socio-economic status, and other patient-level characteristics may lead to untruthfulness. Practitioners should avoid spontaneous judgments and assume a neutral position. Understanding the spectrum of responses a patient can have will allow for appropriate follow-up. Identify the cause of dissatisfaction and properly address it. Physicians can respond to frustration by validating a patient's unhappiness and then providing a solution. For example, “You seem upset. Can we go through the plans for your care together and see how we can help you succeed”? The physician can use appropriate body language to show empathy and care. If one chooses to touch a patient, the shoulders are the most appropriate locations.
Effect on Patient Satisfaction
In addition to improving patient satisfaction, physicians ultimately want to reduce the number of times patients have to be hospitalized or visit specialists. Positive patient interactions correlate with better emotional recovery and decreasing follow up imaging and referrals. Patients are more apt to comply with treatment, and appropriate follow up if they have a better understanding of their prognosis. Additionally, effective communication not only reassures patients but also lowers the rate of malpractice claims and complaints. Inadequate doctor-patient communication increases the dissonance between the physician and patient, which can negatively impact the confidence patients have in their physicians. Patient-centered communications have also correlated with higher job satisfaction, reduced work-related fatigue, and stress.
Maintaining a positive attitude and believing that patients can recover is an important motivator to the provider. If patients sense that the physician or other provider is offering positive social support, they may be less apt to give up on themselves. It is important to realize that patients seek assistance in some of the most vulnerable and sensitive moments in their lives. Patients may have experienced some form of socioeconomic hardship and have resorted to using substances as a coping mechanism. Furthermore, explaining a diagnosis transparently gives patients the sense that the disease is treatable and offers closure and peace of mind.
Shared Decision Making
Healthcare is shifting from a period in which physicians “know best” because they spent numerous years on education, and therefore their recommendation should be taken firmly, to an era of informed consent. Appropriate patient communication exemplifies satisfactory interpersonal relationships, information exchange, and involvement in decision-making. Management of a patient’s illness should take into account their patient-level characteristics, including their socioeconomic background, expectations, and preferences. For example, what role does insurance play in covering their care? Given their social situation, how will they react to the associated side effects of a medication?
Decreasing Patient Anxiety
Organize information before speaking with the patient. Specific instruction is associated with higher compliance. [Level IV]
Reminding patients of upcoming appointments and assisting with referrals can also yield higher compliance. [Level III]
Productive communication programs, such as videotaping patient encounters, provide feedback. [Level V]
Interact with patients when there are no administrative duties to perform, such as drawing blood or administering medication. For example, ask about how their day is going or ask if they have any worries. [Level II]
Health care providers should be made aware of some “red flags” that indicate heavy substance abuse disorders. Some signs include the smell of alcohol on breath, aggressiveness, abnormal gait, slurred speech, impaired judgment, or withdrawal symptoms. Patients with substance abuse disorders may also have difficulty maintaining friendships, staying interested in hobbies, or be struggling financially. They may also have prior records of driving under the influence, involvement in assaults or domestic violence, theft, or drug possession.
|||Markides M, The importance of good communication between patient and health professionals. Journal of pediatric hematology/oncology. 2011 Oct; [PubMed PMID: 21952568]|
|||Street RL Jr,Makoul G,Arora NK,Epstein RM, How does communication heal? Pathways linking clinician-patient communication to health outcomes. Patient education and counseling. 2009 Mar; [PubMed PMID: 19150199]|
|||Duffy FD,Gordon GH,Whelan G,Cole-Kelly K,Frankel R,Buffone N,Lofton S,Wallace M,Goode L,Langdon L, Assessing competence in communication and interpersonal skills: the Kalamazoo II report. Academic medicine : journal of the Association of American Medical Colleges. 2004 Jun; [PubMed PMID: 15165967]|
|||Koch-Weser S,Dejong W,Rudd RE, Medical word use in clinical encounters. Health expectations : an international journal of public participation in health care and health policy. 2009 Dec; [PubMed PMID: 19709316]|
|||Ha JF,Longnecker N, Doctor-patient communication: a review. The Ochsner journal. 2010 Spring; [PubMed PMID: 21603354]|
|||DiMatteo MR, The role of the physician in the emerging health care environment. The Western journal of medicine. 1998 May; [PubMed PMID: 9614789]|
|||Cheatle M,Comer D,Wunsch M,Skoufalos A,Reddy Y, Treating pain in addicted patients: recommendations from an expert panel. Population health management. 2014 Apr; [PubMed PMID: 24138341]|
|||Chipidza F,Wallwork RS,Adams TN,Stern TA, Evaluation and Treatment of the Angry Patient. The primary care companion for CNS disorders. 2016; [PubMed PMID: 27733956]|
|||Lee SJ,Back AL,Block SD,Stewart SK, Enhancing physician-patient communication. Hematology. American Society of Hematology. Education Program. 2002; [PubMed PMID: 12446437]|
|||Stewart M,Brown JB,Donner A,McWhinney IR,Oates J,Weston WW,Jordan J, The impact of patient-centered care on outcomes. The Journal of family practice. 2000 Sep; [PubMed PMID: 11032203]|
|||Arora NK, Interacting with cancer patients: the significance of physicians' communication behavior. Social science [PubMed PMID: 12850107]|
|||Becker MH,Maiman LA, Strategies for enhancing patient compliance. Journal of community health. 1980 Winter; [PubMed PMID: 7204635]|
|||Foote A,Erfurt JC, Controlling hypertension: a cost-effective model. Preventive medicine. 1977 Jun; [PubMed PMID: 406608]|
|||Levinson W, Physician-patient communication. A key to malpractice prevention. JAMA. 1994 Nov 23-30; [PubMed PMID: 7646617]|
|||McGilton K,Irwin-Robinson H,Boscart V,Spanjevic L, Communication enhancement: nurse and patient satisfaction outcomes in a complex continuing care facility. Journal of advanced nursing. 2006 Apr; [PubMed PMID: 16553689]|
|||McCabe C, Nurse-patient communication: an exploration of patients' experiences. Journal of clinical nursing. 2004 Jan; [PubMed PMID: 14687292]|
|||Nadzam DM, Nurses' role in communication and patient safety. Journal of nursing care quality. 2009 Jul-Sep; [PubMed PMID: 19525757]|
|||Mersy DJ, Recognition of alcohol and substance abuse. American family physician. 2003 Apr 1; [PubMed PMID: 12722853]|