“Primum non plus nocere quam succurrere.” Above all else, do not harm more than succor.
Introduction
The consequences of poor communication in the delivery of health care can be dire, to say the least. Ultimately, poor communication can lead to unwarranted injury and death. A study assessing 10 years of malpractice lawsuits found that breakdowns in communication were one of the top three most prevalent factors contributing to malpractice lawsuits. The impact of miscommunication on patient safety is likely to be an even bigger issue when one considers that these statistics are solely based on actual lawsuits filed. Thus communication practices should be duly scrutinized as they relate to the ethical edict of “do no harm.” In the American Academy of Physician Assistants (AAPA) guidelines for the ethical conduct of the physician assistant (PA) profession, nonmaleficence is one of the four bioethical principles. Nonmaleficence means to do no harm or to not impose an unnecessary or unacceptable burden upon the patient. Conscious and deliberate communication within the delivery of medical care is essential to minimize costly errors. There are many benefits to effective patient-centered communication. For one thing, patient-centered communication improves patient satisfaction and safety and contributes to improved health outcomes. For another, successful communication can help to overcome health care disparities by removing biases from the conversation. When communication is successful, it can also positively affect provider job satisfaction. The potential that the right communication has to improve health outcomes, reduce medical errors, and even improve provider job satisfaction makes it a crucial point of discussion. This chapter focuses on five areas of communication in health care. These areas are patient-centered communication, health literacy and cultural competency, interprofessional communication, information technology (IT), and professionalism.
Patient-centered communication
Research has shown that no matter how knowledgeable a clinician might be, if the clinician is not able to engage in good communication with a patient, the clinician may be of no help at all. , A patient-centered approach to delivery of care improves communication and is an effective means to improve health outcomes and patient satisfaction. Patient-centered care starts with patient-centered communication. Patient-centered communication involves creating a sustainable health care provider–patient relationship. A sustainable relationship explores the patients’ perspective, expresses emotional experiences, demonstrates empathy, and engages in shared task-finding and shared decision making. Patients who are able to negotiate the best plans of care with their clinician have been shown to have had better success at achieving healthy lifestyle changes and adhering to treatment plans. Appropriate communication skills are also critical in managing emotionally charged situations, such as trauma and end-of-life situations.
How does the clinician know how well communication with the patient is going? Effective patient–provider communication is measured by the patient’s ability to follow through with medical recommendations, to self-manage chronic medical conditions, and to adopt preventive health behaviors. Effective communication also hinges on subjective feedback about the patient and provider’s feelings of the communication exchange. How one perceives the patient–provider relationship influences the experienced quality of communication. Therefore strengthening interpersonal relationship skills is an important component of care.
There are two major communication obstacles in health care delivery that are problematic to communication. These are communication breakdowns and common communication barriers. Breakdowns and barriers in communication hinder effective and collaborative communication. Identifying where these obstacles occur in patient-centered care and communication will help promote successful encounters.
Communication breakdowns
Breakdowns in communication occur because of ineffective or incomplete communications between the clinician, the patient, and the patient’s caregivers. Even when being especially careful, all forms of communication are at risk for miscommunication. When are these breakdowns most likely to happen? Communication breakdowns occur across the continuum of care and often involve ambiguity regarding responsibilities. Communication breakdowns result in incomplete or misunderstood diagnostic and therapeutic instructions and subsequently have a negative effect on patient mortality and morbidity. In patient referrals, quality of care often suffers from interprofessional miscommunication, which can lead to poor continuity of care, unnecessary diagnostic procedures, delayed diagnoses, polypharmacy, and increased litigation risk.
Effective communication relies on the patient and everyone involved in the patient’s care to be clear and in sync. The patient and the caregivers must be clear about the plan and understand their tasks and responsibilities in carrying out the plan. The degree to which this happens positively affects patient safety and treatment adherence, leading to improved health outcomes.
Barriers to communication
Communication is a reciprocal process. Differences in knowledge, perceptions, and ideas are a part of a normal and healthy human to human engagement. These differences usually cause disagreement, misunderstanding, and conflict. Nevertheless, the communication process remains unharmed when disagreement is managed constructively. Principles for successfully managing conflict involve active listening by making it clear that the messages are being heard, thinking before reacting, engaging in a fair and conscientious manner, keeping the focus on the problem and not on personal issues, and finding mutual gains in the resolution. Besides conflict, other common barriers of communication are perceived differences and competency in language, education, cultural responsiveness, and health literacy. Lack of perceived courtesy, respect, and engagement are also common recurring themes in barriers to effective health care communication.
A specific barrier to clinician–patient communication is patient interruptions, particularly as they relate to the time constraints of the patient encounter. The skill and art of history taking are the most important parts in the diagnostic workup of patients for practicing clinicians. An estimated 70% to 90% of diagnoses are made from the patient’s history alone. Studies of clinician–patient visits, unfortunately, show that patients are often not provided the opportunity to tell their stories. This is often because of time constraints and interruptions, which compromise diagnostic accuracy. In such circumstances, the patient may perceive that what he or she is saying is not important to the clinician, which can lead to the patient feeling reluctant to offer additional information. When patients are interrupted, the provider risks the opportunity of collecting essential information. If a patient feels rushed or interrupted, this can further undermine the patient–provider relationship.
Besides weakening the patient-provider relationship, there are other consequences to ineffective communication. The most dangerous consequences of barriers to communication are those that lead to medical errors. Research has shown that written communication is the most prevalent form of communication in the health care setting. Therefore it stands to reason that note writing, discharge summaries, follow-up instructions, and prescription writing must be very clear and accurate. Medical errors occur when medication lists are inaccurate, instructions are incomplete or lacking, and communication between specialists is inconsistent. This becomes even more of a danger when the patient does not feel like he or she shares in the decision-making process and either does not feel capable of questioning the caregiver or is unable to reach the ear of the caregiver.
Health literacy and cultural competency
Health literacy is a broad term with a specific purpose of alerting health care providers to a significant barrier to equitable access and use of health care. Poor health literacy is not simply a matter of one’s educational level, language skills, culture, or ethnicity. There are many components that can contribute to poor health literacy, and health literacy is important and applicable to everyone. Ultimately, anyone who needs any type or form of health care services needs health literacy skills. Many studies have shown a link between poor health literacy and poor health outcomes. This equates to health disparities.
Health literacy is defined by the Institute of Medicine’s report, Health Literacy: A Prescription to End Confusion, as “the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.” More recently, the definition has been broadened to include a focus on the specific skills needed to navigate the health care system and the importance of clear communication between health care providers and their patients.
Poor health outcomes caused by poor health literacy place a responsibility on health care providers to not only be cognizant of poor health literacy as a major health disparity but also to remain vigilant against it in practice. Overcoming health literacy problems for improved patient outcomes is an achievable task. The first step is to recognize the factors involved in creating the disparity with the individual or community served, and the second is to implement tools to overcome these disparities. Common identifiable factors impeding health literacy have been illuminated in many studies. These include how information is communicated, past experiences with the health care system, the format of the deliverables, linguistic and cultural variables, access to health care, age, socioeconomic status, and the quality of the patient–provider relationship.
Research linking ways to overcome poor health literacy and improve health outcomes is ongoing. Some ways to overcome literacy barriers have become common practices, such as printing patient information in different languages and delivering information in plain language that cuts out the practice-specific jargon. Strategies such as tailored and targeted health communications that enhance the relevance of the information to the target audience have also shown some promising benefits.
Showing cultural respect can overcome major components of health literacy having to do with ethnicity, equity, and access to care. When a clinician is respectful and responsive to health beliefs, cultural beliefs and practices, and linguistic needs, studies show there is remarkable efficacy in decreasing disparity and providing high-quality access to care. Conversely, when patients experience a stereotype threat in a clinical setting, it can have devastating effects on health outcomes and can be considered a health disparity.
It is imperative to teach current and future clinicians the skills of cultural competency, cultural respect, and cultural humility. Cultural competency is the ability to incorporate a set of behaviors, attitudes, and policies that come together in a system or among professionals that enable effective work in cross-cultural situations. Cultural competency is an important skill to possess to overcome barriers to health care access, patient safety issues, and overall outcomes in terms of screening, diagnostics, and treatment adherence. Attaining cultural competency begins by self-reflection, and it requires an honest, ongoing assessment of biases that can impede delivery of care caused by a lack of respect and understanding toward patients or other health professionals.
The number of cultures that exist on this planet are too numerous to count. Our culture dictates our values, beliefs, behavior, and attitudes. Acquiring the skill to respect a culture begins with acknowledging the extent to which culture influences lives. Fully respecting a culture is demonstrated by acknowledging that regardless of the cultural differences at play, patients remain welcomed and encouraged to take part in the decisions and management of their care.
Cultural humility is related to, yet different from, the concept of cultural competency. Cultural humility involves an ongoing process of self-exploration, self-reflection, and a willingness to learn from others. It means entering into relationships with the intention of honoring other’s beliefs, customs, and values. Acquiring this skill requires constant attention to how our explicit and implicit biases affect our relationships. It is important to remain open-minded and be accepting of differences.
Interprofessional communication
At the forefront of helping professional programs implement and integrate interprofessional team-based, patient-centered care practices into the curriculum of health care professionals is the Interprofessional Education Collaborative (IPEC). IPEC is a cooperative organization made up of health care disciplines involved in patient care. It promotes and encourages coordinated efforts to advance substantive interprofessional learning experiences to help prepare future health caregivers to function in a team-based model, thereby improving population health outcomes. This collaborative created core competencies for interprofessional collaborative practice to guide curriculum development across health profession schools. Ideally, it has fostered an environment for team-based interprofessional communication beginning at the developmental stages of a students’ education.
Since the implementation of IPEC in 2009, there has been much more emphasis on the importance of communication between providers, patients, and the full health care team. By definition, interprofessional education (IPE) is “when two or more professions learn with, about and from each other to enable effective collaborative outcomes.
Before IPEC and the introduction of the Triple Aim goals for reforming health care in the United States, many clinicians were trained and essentially worked in silo-based care. Silo-based care, however, is quickly becoming an entity of the past. This is especially true considering the number of patients who are managed by multiple types of health care providers, the introduction of electronic health records (EHR) for communication among patients and providers, and other health information technology, such as telehealth, which is gaining more momentum in use. Other factors that affect our daily regimens include requirements of managed care and engaging in the administrative side of health care, such as in billing and coding. It is almost impossible to work a full clinical day without working collaboratively with others.
As clinicians, we learn how to be most effective and efficient with our time and patient schedules with the intent of patient care being the priority of our focus. At times, however, patient-centered communication is hindered by the use of EHR. Instead of spending more time with patients, time is spent on electronic communications in a dark room, at a station, or even on our phones completing dictations and reviewing diagnostic results. This paradoxical relationship, according to some research, actually has clinicians spending less time with their patients and more time with their electronics.
On the other hand, EHR has helped to improve medical errors, specifically in terms of legibility issues and the clarity of electronic prescriptions. It has helped to improve billing and coding efforts where individuals are prompted to link a diagnosis code to an order such as a radiographic imaging study, and it has tremendously improved the ability to access information remotely from any location. The pros and cons of communicating electronically need to be balanced effectively so it can provide interprofessional communication and accurate information without being a distraction or time deterrent from patient-centered care.
With so many moving parts in the way everyone communicates today, interprofessional education is, rightly so, a part of the PA curriculum and is part of the accreditation standards for many other health professions as well. IPEC’s general communication competency domain stresses the need to “communicate with patients, families, communities, and other health professionals in a responsive and responsible manner that supports a team approach to the maintenance of health and the treatment of disease.” How to incorporate interprofessional communication into the curriculum and assess a student’s competency in this domain, however, can be challenging.
The national Physician Assistant Education Association (PAEA) is listed as one of the supporting organizations (among many) on the IPEC primary website. IPEC training that includes simulation experiences has shown not only to be supportive to PA students’ learning but also has a strong influence on graduates’ success in transitioning to the workforce. Many potential employers view interprofessional training received by a new graduate as an asset. Interprofessional training that culminates in its own certificate or badge can even help new PA graduates stand out from other candidates because it ascertains an individual’s interprofessional and interpersonal attained skills. New graduates can directly apply interprofessional competent and collaborative care to the clinical practice.
Another area in health care that has drastically changed the approach and direction of the management of medicine has been the introduction of the Triple Aim goals for reforming health care in the United States. The Triple Aim has fostered the advocacy for patient- and population-centered health care delivery using teams of professionals. The Institute for Healthcare Improvement developed the Triple Aim framework, which seeks to improve the quality of health care through three dimensions: (1) improving the patient experience of care (including quality and satisfaction), (2) improving the health of populations, and (3) reducing the per capita cost of health care.
Perhaps the most familiar entity evolving from the Triple Aim is the patient-centered medical home (PCMH). A PCMH is a patient-centered health care delivery model that is team based to provide comprehensive health care. PCMHs are believed to improve health outcomes, safety, and quality of care and provide a more efficient use of practice resources.
Interprofessional collaboration involves relaying and receiving vital clinical information from one profession to another concerning patient care. This underscores the importance of effective, efficient, and comprehensive communication practices to prevent adverse patient care outcomes. Communication mishaps resulting in safety issues and medical errors arising from professionals working with other professionals is certainly not new. In fact, it remains a hot topic in the delivery of quality of care. As a result, effective communication tools and resources have been developed and implemented in health care settings that reduce adverse patient outcomes. The following are some examples:
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TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety)
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ISBAR (Introduction, Situation, Background, Assessment, and Recommendation) ( Fig. 14.1 )
