Definition/Introduction

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.[1][2] Furthermore, providers can better manage interventions, referrals for treatment, and assessments of patients’ willingness to change with more effective communication tools.[3]

Issues of Concern

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.[4]

Studies have shown that physicians do not disclose enough pertinent information to patients, which can impact a patient’s involvement in their care.[2] Proper communication allows patients to be more knowledgeable about their prognosis and to be more proactive in seeking assistance.

Non-verbal Communication

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.

Physician Attitudes

Medical school, residency, fellowships, and long careers often take both an emotional and physical toll on physicians.[5] As a result, their ability to empathize with patients decreases over time and may often lead to the belittling of patients.[6] 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.[7]

Patient Anxiety

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.

Irritable Patients

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.[8] 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.[9] If one chooses to touch a patient, the shoulders are the most appropriate locations.

Clinical Significance

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.[10] 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.[5] 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.[5]

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,[1] to an era of informed consent. Appropriate patient communication exemplifies satisfactory interpersonal relationships, information exchange, and involvement in decision-making.[3][11] Management of a patient’s illness should take into account their patient-level characteristics, including their socioeconomic background, expectations, and preferences.[6] 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?

Solutions

Decreasing Patient Anxiety

• Ask for permission to gather specific information that could improve their care. Be transparent. Explain why such information is useful. 

• If confidentiality issues arise, address them appropriately. Inform patients on the legal responsibility of the provider to safeguard patients from unauthorized disclosures. However, recall that patient-physician confidentiality is usually preserved but does not guarantee full protection from legal discovery. Physicians must report information if a patient is harming himself/herself/others or is involved in domestic violence. Legal policies and procedures differ from state to state.

• Providers need to be cautious of how they word questions, keeping questions professional but understandable. For example, instead of saying “illicit” drugs, say “street” or “recreational” drugs. Avoid subjective words such as “healthy,” “drunk,” “happy,” or “sad,” as these words have different meanings to different people.

• Ask close-ended questions and offer response choices. Asking closed-ended questions increases specificity, which increases the likelihood of getting an accurate history and reduces stress for the patient. For example, instead of “Do you use cocaine?” ask, “How often do you do cocaine? Daily? Weekly? Monthly? Yearly”?

• Ask for pertinent history, such as the frequency and duration of their drug. For example, identify current and past drug use, frequency of drug use, and assess for dependency to determine proper treatment and referral. For example, “Have you used meth”? “How often do you use meth”? “On a scale of 1 to 10, how likely are you to quit”?

• Normalize the problem by saying a generalizing statement. For example, use words such as “These are routine interview questions that I ask all my patients… ”. By doing so, patients feel like they belong to a generalized group and that they are not the only ones with problems. If patients understand that they are part of a collective community, they may be more inclined to be open.

• Explain your medical reasoning behind your diagnosis and plan in layman’s terms. 

Nursing, Allied Health, and Interprofessional Team Interventions

Organize information before speaking with the patient. Specific instruction is associated with higher compliance.[12] [Level IV]

Reminding patients of upcoming appointments and assisting with referrals can also yield higher compliance.[13] [Level III]

Productive communication programs, such as videotaping patient encounters, provide feedback.[14] [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.[15] [Level II]

Nursing, Allied Health, and Interprofessional Team Monitoring

Nurses should:

• Address patients appropriately. Do not refer to patients by associating them with their disease process ("the patient with hypertension," "the patient with bilateral tibia/fibula fracture").
• Talk to patients as if they were individuals rather than assignments.[16]
• Not rush patients.
• Be readily available and accessible in case patients call for assistance.
• Recognize patients' feelings and know that their feelings require acknowledgment.[16]
• Observe patients' physical and psychological well-being.[16] 
• Offer patients the chance to ask questions and assess their understanding of the issues to resolve misunderstandings.
• Be trained on professional behavior, including proper etiquette, how to behave with emotional patients, and how to handle disruptive team members.[17] 

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.[18]