Communication Commentary: Effective Patient-Centered Communication
“We do not believe in ourselves until someone reveals that deep inside us something is valuable, worth listening to, worthy of our trust, sacred to our touch.”E.E. Cummings
Caring for patients with psychiatric disorders requires careful listening, active engagement, and skillful communication for full therapeutic benefit—whether the intervention includes psychotherapy, psychopharmacology, case management, effective collaboration with systems of care, working with families, or any combination of these interventions. Yet, psychiatric practice raises a number of potential barriers to effective patient-centered communication. The effects of stigma and serious psychiatric or substance abuse illness may compromise the patients' decision-making capacities and lead to more coercive measures to ensure safety and appropriate treatment for their disorder. Psychiatric care is often “carved out” of insurance plans, and this may be a barrier to optimal coordination of systems of care. Reimbursement parameters for medical practice often optimize payments for procedures and very brief medication “checks,” with poorer reimbursement for the time required for active patient engagement in his or her treatment plan. Each person in psychiatric care is unique. Meeting each individual patient's needs requires expertise in effective communication skills in the evaluation and treatment of individuals with the full array of psychiatric and substance use disorders, and from disparate cultures, life styles, religions, and value systems (1–4).
The primacy of effective listening and communication for optimal patient care has prompted the Communication Commentary section of FOCUS. Although psychiatrists may excel in listening and communication skills as a key tool for therapeutic interventions, there are many special considerations in psychiatry that both facilitate and hinder effective patient-centered communication. Every psychiatrist and psychiatrist-in-training should be aware of issues related to effective communication in medical practice generally, and in psychiatric practice more specifically. The Communication Commentary is designed to highlight potential communication dilemmas faced in the field and provide information and best practice, and, when available, evidence-based discussion to enhance lifelong learning of this essential skill.
Principles of patient-centered care
Ms. Jones left the first appointment with her psychiatrist with a sense of relief, yet with a vague sense of unease. She had finally agreed to see the psychiatrist at the suggestion of her primary care physician, whom she had asked for medical excuses for her multiple absences from work for symptoms of fatigue, lack of energy and motivation, weight loss, sleep difficulties, and crying spells. A medical workup had been “negative, and her primary care physician felt that she needed a thorough evaluation of her likely serious depression. Ms. Jones had liked the psychiatrist. She was kind and took her symptoms seriously. She gave Ms. Jones a prescription for an antidepressant medication, and, for the first time in months, Ms. Jones felt that there was hope that she would finally begin to feel better. However, as Ms. Jones recounted to her best friend, the risks of the medications had been reviewed “like a TV ad that concludes a lovely scenario of happy people frolicking at the beach with a speed-talker that rushes through all of the possible side effects.” She was most concerned about possible sexual side effects of the medication, as her sex life was the only aspect of her life in which she still felt truly “alive” and fulfilled. Yet, she had felt too embarrassed to bring it up. “I felt like I was in high school again, being too nervous to ask for birth control,” she confided to her friend. “My psychiatrist knows what she's doing, but I don't think she understands me and my needs very well. How do I know if the medication I was prescribed is the least likely to have sexual side effects?” Her friend laughed and replied wryly, “Why do you think they invented the Internet, silly?”
In 2001, the Institute of Medicine published a report, Crossing the Quality Chasm: A New Health System for the 21st Century (5). The report delineated a strategy for improving overall health care, which included six aims of high-quality health care: safe, effective, patient-centered, timely, efficient, and equitable. Patient-centered care was defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions” (pp. 5–6). Patient-centered care requires effective patient-centered communication skills. Patient-centered communication occurs when the provider facilitates the patient's perspective and the psychosocial context of his or her illness, shares information with the patient in a transparent manner, gives the patient control over health care decisions, and elicits the patient's individual preferences for health care delivery options (1, 5, 6). As the case report above illustrates, patient care is not optimal without close attention being paid to the patient's individual needs and values.
Special communication challenges in psychiatry
A follow-up Institute of Medicine report in the Quality Chasm Series (1) addressing health care for mental and substance use conditions, postulates that individuals with mental health and substance use (MH/SU) illnesses receive care that is less patient-centered because of negative stereotypes that stigmatize these individuals: misperceptions about the extent to which individuals with MH/SU disorders are capable of making informed decisions about their treatment and erroneous beliefs about the level of danger that these individuals pose to themselves and others. This stigma influences how individuals with MH/SU illnesses are perceived by others and also how they perceive themselves, leading to decreased self-efficacy, less ability to self-advocate, and diminished health care outcomes (1–3).
Although there is general agreement among clinicians and educators that “patient-centered care” is desirable, there is very little research on the topic. In fact, very few studies have behaviorally defined the provider skills that comprise patient-centered communication and care. Of the randomized controlled studies that used PCC skills, there have been generally two types of models defined concerning the fundamental functions of the patient-centered interview: model 1 for data gathering and emotion-handling; and model 2 for informing and motivating patients regarding specific details of the treatment process (6).
Recommendations of the IOM regarding patient-centered communication
The Institute of Medicine has made the following summary recommendations to clinicians and organizations providing mental health and substance abuse treatment in order to promote patient-centered care (1):
•.
Include active participation of patients in the design and revision of treatment and recovery plans.
•.
Use psychiatric advance directives (patients make their treatment preferences known when they are most healthy so that decisions may be optimally patient-centered in the event they may be in acute psychiatric crisis). For children, this includes informed family decision making.
•.
Provide information on the availability and effectiveness of MH/SU treatment options to help patients make informed decisions.
•.
Adopt illness self-management practices that support patient preferences for treatment.
•.
Maintain effective, formal linkages with community resources to support patient illness self-management and recovery.
•.
Provide education, whenever possible, to help destigmatize mental illness.
Conclusion
Providing patient-centered communication to optimize patient involvement in his or her care poses many challenges but represents a fundamental commitment for the health care field. The obligation to ensure safety of our patients and society and to provide empathic and effective care for patients who are too ill to make fully informed decisions must be counterbalanced with our obligation to ensure optimal patient autonomy, fight stigma regarding presuppositions of dangerousness of patients with MH/SU disorders, and attempt to optimize communication that assists patients in taking the most active role possible in their treatment. More behaviorally defined criteria of the requisite skills for optimal patient-centered communication are needed, such that research may inform our practice and the teaching of these skills to psychiatrists-in-training (1, 7, 8).
REFERENCES
1.
Institute of Medicine: Quality Chasm Series: Improving the Quality of Health Care for Mental and Substance-Use Conditions. Washington, DC, National Academy Press, 2006. http://www.nap.edu/catalog/11470.html
2.
Link B, Struening E, Neese-Todd S, Asmussen S, Phelan JC: Stigma as a barrier to recovery: the consequences of stigma for the self-esteem of people with mental illnesses. Psychiatric Serv 2001; 52:1621–1626
3.
Martin JK, Pescosolido BA, Tuch SA: Of fear and loathing: the role of “disturbing behavior,” labels, and causal attributions in shaping public attitudes toward people with mental illness. J Health Soc Behav 2000; 41:208–223
4.
Cox JL: Empathy, identity and engagement in person-centered medicine: the sociocultural context. J Eval Clin Pract 2011; 17:350–353
5.
Institute of Medicine: Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC, National Academy Press, 2001
6.
Smith RC, Dwamena FC, Grover M, Coffey J, Frankel RM: Behaviorally defined patient-centered communication: a narrative review of the literature. J Gen Intern Med 2011; 26:185–191
7.
Mauksch LB, Dugdale DC, Dodson S, Epstein R: Relationship, communication, and efficiency in the medical encounter: creating a clinical model for a literature review. Arch Intern Med 2008; 168:1387–1395
8.
Cegala DJ: Emerging trends and future directions in patient communication skills training. Health Commun 2006; 20:123–129
Information & Authors
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Published online: 1 January 2012
Published in print: Winter 2012
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Author Information and CME Disclosure
Dorothy Stubbe, M.D., Associate Professor and Program Director, Yale University School of Medicine Child Study Center, New Haven, CT. Dr. Stubbe reports no competing interests.
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