Communication Commentary: Patient Engagement in Psychosocial Interventions

Barry and colleagues (6) described the importance of the matching of communication style between doctor and patient—specifically, matching the voice of medicine (the language and understanding of the physical medical problem) and the voice of the lifeworld (the multifaceted, contextualized, and meaningful patient narrative, which includes hopes and fears). They researched the communication styles of doctors and patients via patient interviews, doctor interviews, and transcribed consultations across 35 general practice case studies. Their results suggest that for simple medical problems (e.g., an ear infection) the doctor and patient may communicate effectively when they both use the voice of medicine exclusively (strictly medicine). When both doctor and patient engaged with the lifeworld, more of the patient’s personal agenda and concerns were voiced (mutual lifeworld) and patients felt recognized as unique individuals (psychological plus physical problems). This mutual communication pattern was less common than communication in which the doctor used the voice of medicine, but adherence rates were noted to significantly improve with mutual lifeworld conversations. However, patients were noted to be reluctant to voice their personal agenda and true concerns unless specifically asked, frequently placing the onus on the physician for beginning the mutual lifeworld discussion. The poorest outcomes occurred when patients used the voice of the lifeworld but were ignored (lifeworld ignored) or blocked (lifeworld blocked) by the doctors’ use of the voice of medicine. This happened most commonly for patients with chronic and/or nonspecific physical complaints. The analysis supported the premise that increased use of the lifeworld makes for better outcomes and more humane treatment of patients as unique human beings (6).

A further component of compliance relates to the doctors’ ability to listen attentively, to demonstrate interpersonal fairness (7), and to accurately “read” their patients’ nonverbal behavior (8). Social and cultural variables may also play a role. Patients whose doctors are more sensitive to their nonverbal communication are more satisfied and have better health outcomes (8). A study by DiMatteo and colleagues found that the doctor’s nonverbal sensitivity was correlated with the patient’s sense that the doctor understood and cared about them (9). The patient whose doctor demonstrated high nonverbal sensitivity tended to like the doctor more and described the doctor as compassionate (10). In addition to enhanced patient satisfaction, doctors who were more skilled in interpreting patients’ nonverbal behavior tended to have fewer appointment cancellations, better overall patient understanding of the treatment plan, and greater adherence to treatment recommendations (9, 11). Evidence has accrued that physicians generally, but especially those that are of White ethnicity, have a more difficult time accurately interpreting the nonverbal communication of non-White patients. Missing or misinterpreting these nonverbal cues presents a barrier to full and accurate communication. This may negatively impact patient engagement and treatment adherence, and inadvertently contribute to racial disparities in patients’ satisfaction and health outcomes (8, 12).

The electronic medical record (EMR) has complicated doctor-patient communication. The need to enter the information obtained into the record may interfere with doctor-patient communication by decreasing the time of directly looking at the patient and reading of nonverbal cues (13). However, a study by Silverman and Kinnersley (14) suggested that physicians may learn methods to overcome the interpersonal distancing, both verbally and nonverbally, with which computer use is associated. For example, first talking to the patient without looking at the computer is suggested. Collaborative reading of the EMR, and completing the encounter notes jointly with the patient to ensure understanding and accuracy may actually contribute to improved quality of care, enhance the decision-making process, and empower patients to participate in their own care.

Although some physicians may come to the profession with attuned listening skills and a refined ability to read nonverbal cues, some do not, and probably all will benefit from practice. Physicians who are effective communicators have a 19% higher rate of patient adherence to recommendations than those who are less-skilled communicators (11). However, as DiMatteo and colleagues have described (4), physicians may significantly improve their communication skills through training. In fact, some medical schools have adopted a curriculum to help students “unlearn” automatic biases (15), practice cross-cultural understanding of facial expressions (16), and train in microexpression recognition of their patients’ nonverbal cues. These curricula have demonstrated positive effects in terms of medical students’ comfort levels with individuals of other racial backgrounds and appear to enhance cultural competence and the ability to connect with patients of all socio-cultural backgrounds (17). Psychiatric training emphasizes empathic engagement, and psychiatrists have been shown to exhibit better listening skills than nonpsychiatric physicians overall (18). However, skilled communication requires ongoing practice, with attention to ethnic and cultural, socio-economic, transference, countertransference, and projective identification factors as they relate to the therapeutic engagement of each unique patient. This engagement engenders authentic communication that may lead to improved adherence and more permanent positive behavioral change (18,19).