Keywords: Communications, Patient Education, Shared Decision-Making

Learning Objectives:

At the end of medical school, the student will be able to:

1. Apply effective communication skills to develop a rapport with patients.
2. Implement shared decision-making into practice.

Introduction

Excellent communication between all members of the health care team is associated with improvements in clinical outcomes, adherence to treatment plans, and provider engagement and satisfaction.  Although patients prioritize clinical competence, a physician who shows concern and who listens is also highly regarded.  As surgical subspecialists, urologists must be adept at navigating concern-based visits, surgical urgencies and emergencies, and patient relationships of variable duration.

Effective communication in the clinical setting, like any other skill, can be learned and improved, and requires deliberate practice and implementation.  We describe six basic communication skills that all providers should have, and then apply them to present strategies to deliver bad news and display cultural humility- important scenarios commonly faced in the urology clinic.

Establishing rapport

All members of the healthcare team should introduce themselves and their role, and appropriately greet relatives or companions present with the patient.

Challenges, such as a prolonged wait time or construction in the parking area, should be acknowledged. 

Many providers like to make a personal connection with patients, for example, asking a pediatric patient what they like to do for fun.  This helps you to gain an understanding of what your patients do outside your office and may help you to better understand them as people.

Eliciting the other’s perspective

Key to this step is the use of open-ended questions.  The mnemonic “ICEE” is helpful:

            Ideas: what does the patient think is happening?

            Concerns: what is most worrying the patient?

            Effects: what effects does the presenting concern have on the patient?

Expectations: what does the patient hope to get out of today’s visit?

When asking these questions, make every effort to understand the patient’s values, not simply their goals, and do not make assumptions.  For example, a patient who says “I absolutely don’t want surgery” may have an ill partner at home and little or no caregiving assistance.  Open-ended questions invite patients to share information to the extent that they feel comfortable and allow contextualization of the patient’s health concerns—and possible treatments.

Recognizing emotions and demonstrating empathy

Empathy, or a recognition and response to the emotions expressed by others, can be verbal or nonverbal. 

Nonverbal expressions of empathy

Eye contact

Leaning forward toward patient, while honoring patient’s personal space

Using facial expressions to demonstrate engagement

Touch (for some patients, and only when personal space can be honored)

Avoid crossing the arms and legs during conversation, as this may signal rigidity or a refusal to consider the patient’s perspective.

Verbal expressions of empathy may take many forms.  The mnemonics “PEARLS”, “NURSE”, and “SAVE” are helpful for some providers.  Not all empathic statements resonate with all providers (or patients).  Some options include:

PEARLS

Partnership

We are in this together.

Emotion

You seem very frustrated.  (Note the use of “seem” rather than are.”)

Apology/appreciation

I’m sorry this has been so challenging. I appreciate how much you have done.

Respect

You are doing a great job with your timed voiding.

Legitimization

Anyone would feel anxious.

Support

I’m going to be here with you through this process.

 

NURSE

Naming

You seem angry.  (Again, notice the use of “seem” rather than “are.”)

Understanding

Your explanation helps me understand why that medication won’t work for you.

Respecting

I am so proud of you.

Supporting

I am here to help you.

Exploring

I am curious what you meant by that?

 

SAVE

Support/partnership

Let us work on getting you to where you want to be.

Acknowledgement/respect

I’m honored that you could share this very personal information with me. I look forward to working together on this journey.

Validation/legitimation

It is very understandable that you are nervous- anyone would be in this situation.

Emotion naming

I can hear how frustrating this may be for you.

Managing Patient Problems and Patient Education

After establishing a relationship with a patient and building rapport, it is important to transition the conversation to present/educate on a new diagnosis or examine how the patient is managing a previous diagnosis. The ARIA mnemonic can help as follows:

Assess: Assess the patient’s understanding of a new diagnosis and/or their concerns or knowledge of a prior diagnosis that is currently being managed.

Reflect: Reflectively listen and demonstrate appropriate empathy as the patient shares their understanding of the diagnosis/knowledge of the problem. The mnemonics above can be employed in this stage.

Inform: Clarify any misconceptions in a non-judgmental manner, and transition to informing the patient of relevant treatment options.

• Part of this aspect is to assess the patient’s health literacy, including whether they are able to independently read instructions or written material from a healthcare provider, fill pharmacy prescriptions, and take medications.

Assess: Assess and validate the patient’s emotions and reaction toward the diagnosis/treatment options that are discussed.

• It is essential to elicit patient preferences regarding treatment options after a careful discussion of the benefits, risks, and alternatives.
• When negotiating the treatment plan, work with the patient to develop a mutual understanding and an agreeable decision.

Using teach-back

On average, patients only remember about half of what they are told, which is understandable given the large volumes of new information that is shared in stressful situations.

Teach-back is a skill that facilitates exchange of information between two parties, ensuring that both have the same understanding, and inviting opportunities for questions and trouble shooting.

Teach-back, in its simplest form, involves information sharing from one person to another, ensuring clarity, and a summary by the receiver of the pertinent information.  It is best to split the information to be taught into smaller amounts and check with the recipient periodically (“chunk and check”).

Person 1 shares information with Person 2:

“I would like you remove your bandage two days after surgery.  It should pull off easily but if it feels stuck, you can soak in the tub for a short bath and then try to remove the dressing.”

 

Person 2 asks for clarification if there is information that is incomplete or poorly understood:

“Do I take the bandage off in the morning or the afternoon?”

 

Person 1 provides clarification until no further questions are raised:

“Great question.  The morning is fine.”

 

Person 2 summarizes information to Person 1:

“Okay, so I will remove the dressing on Thursday morning, and if I have trouble, I’ll soak in the tub for 5 minutes and try again.”

Implementing shared decision making (negotiation)

Shared decision making is effectively a negotiation between provider and patient wherein each person shares their perspectives, values, ideal outcomes, and non-negotiable events, then use this information to arrive together at a plan of care that honors both perspectives.

While a complete discussion of shared decision making is beyond the scope of this section, it should be remembered that shared decision making is not a one-way conversation, nor is it the simple exchange of information.  It is the process of arriving at a mutually agreed-upon course of action based on an understanding of the risks and benefits of the different options available, taking into account the values and goals of the patient with insight from the provider.

Putting the Skills Together: Delivering Bad News or an Unexpected Diagnosis

As a provider in urology, it can often be challenging to diagnose a patient with a life-changing disease, even if there is an effective treatment. From the patient’s perspective, it is understandable that getting a diagnosis of “incontinence,” “erectile dysfunction,” or “cancer” can be a label that sticks with them to the point that it becomes a part of their identity. The following skills can be utilized to facilitate the process in a conducive, patient-centered manner:

• Part 1- Present the diagnosis.
  • Start by orienting the patient to the reason of the visit by connecting it to their relevant diagnostic test. It may help to explore the patient’s perspective on why the tests were performed.
    • “I would like to discuss the results from the (diagnostic test) that you had last week. What is your understanding of why we did this?”
  • Give the news in a direct and concise manner that is understandable (i.e.: is not filled with medical jargon).
  • Use silence to allow the patient to absorb the news.
• Part 2- Use reflective listening and convey empathy to assess the patient’s emotional response to the news.
  • This is essential to accomplish before jumping to treatment options.
  • The PEARLS, NURSE, and/or SAVE mnemonics can help guide this discussion.
• Part 3- Clarify the patient’s understanding and/or provide additional information about the diagnosis.
  • Use open-ended statements to elicit patient understanding, such as:
    • “Tell me about your understanding of (diagnosis).”
    • “Do you know anyone who has had (diagnosis) or a similar condition?”
  • Part 4- If appropriate, transition the conversation to start outlining treatment or further assessment options, and to establish a plan of care.
    • If the patient would appreciate more time to process the diagnosis and/or handle emotions, this part can be addressed in a follow-up visit.

Putting the Skills Together: Cultural Humility and Social Cognizance

Remember the basics: Avoid labeling and stereotypes! Implementing the mnemonics from above to convey empathy can help respond to each patient’s unique cultural beliefs, values, expectations, and feelings. Key strategies and goals for leading the conversation include:

• Showing interest in a patient’s cultural background and identity:
  • Employing open-ended statements, such as “tell me about your previous experiences in the medical system”, encourages patients to share how their identity has affected their experiences with medical culture and illness.
    • It may also raise some relevant patient concerns that we can pay extra attention to in the current situation.
    • This may be particularly useful in addressing homophobia or transphobia with patients identifying with the LGBTQ+ community.
  • Understanding how a patient’s cultural values may inform perspectives of their disease:
    • Non-judgmentally inquiring about a patient’s cultural background, social context, language/literacy, and socioeconomic background can provide insight into how the patient’s illness is affecting them and their loved ones.
  • Applying the “explanatory model” of illness: Asking some (or all) of the following questions can help us further clarify beliefs, values, expectations, and behaviors that may influence a patient’s perception of their illness and treatment options:
    • “What do you think is causing you to feel this way?”
    • “Do you know of someone who has had a similar problem?”
    • “What aspect of your illness is the most worrisome for you?”
    • “What have you tried to address how you are feeling?”
    • “What are your thoughts on trying x as a possible treatment?”

Additional Resources AUA Core Curriculum: For more content on communication skills, please follow the link below to access the AUA Core Curriculum. Access is free for AUA members and Medical Students qualify for a free AUA membership!  Learn more on our membership page. Communication Skills

References

https://www.ahrq.gov/health-literacy/professional-training/shared-decision/index.html

www.vitaltalk.org

Stimson CJ, Pichert JW, Moore IN, et al.  Medical malpractice claims risk in urology: an empirical analysis of patient complaint data. J Urol 2010; 183: 1971-6.

Hull L, Arora S, Aggarwal R, et al.  The impact of nontechnical skills on technical performance in surgery: a systematic review. J Am Coll Surg 2012; 214: 214–30.

Makoul G. Essential elements of communication in medical encounters: the Kalamazoo consensus statement. Acad Med 2001; 76: 390-3.

Regula CG, Miller JJ, Mauger DT, Marks JG. Quality of care from patient’s perspective.  Arch Derm 2007; 143: 1589–603.

Windover AK, Isaacson JH, Pien LC, et al. Relationship-Centered Healthcare Communication. CreateSpace Publishing; 2014.

Authors

2023
Kathleen Keiran, MD
Seattle, WA
Disclosures: Nothing to disclose

Nityam Rathi
Cleveland, OH
Disclosures: Nothing to disclose