Building the physician-patient relationship

Patient perspective on ‘ideal’ physicians

In a 2006 study, 192 Mayo Clinic patients were asked to reflect on the best and worst experiences they had had with physicians. Patients identified ideal physicians as empathetic, humane, personal, forthright, confident, respectful and thorough. The authors defined each of these in patient terms and described how they could be demonstrated in the clinic. As you reflect on your own experiences, what characteristics would you add to this list? 

Both patient and clinician bring their own personalities, values, beliefs, stereotypes, expectations and experiences to every clinical encounter. Most patients arrive with some combination of illness, anxiety, past trauma, and pain. Recognizing the importance of the relationship to patient care, how can each of us show up as the physicians our patients want and need? 

Nonverbal behavior

Over half of human communication is non-verbal and in the clinic, research shows that nonverbal cues have a significant impact on patients’ satisfaction with their care. In the US, clinicians who smile, lean forward, nod, make more eye contact, and gesture more have more satisfied patients, while more time reading the medical chart has the opposite effect. But the same cue can have a different impact in different cultures and contexts. For example, in a study in Pakistan, most patients agreed that eye contact is a sign that their doctor is paying attention but people preferred brief, regular eye contact to prolonged gaze, which many said made them uncomfortable.

Of course there isn’t a nonverbal cue dictionary for everything that may make your patients, with their intersectional identities and cultures, more or less comfortable. As with all clinical skills, maintain self-awareness, read the room and adjust as needed.

Positioning & posture

Human interactions occur in different spatial zones that convey different messages. Formal communication occurs in the ‘public zone’ 12-20 feet away. The ‘social zone’, 4-12 feet from the individual, is the preferred zone for the first phase of a patient visit. If the conversation becomes more serious or emotional, clinicians may move into the ‘personal zone’ from 1.5 to 4 feet away, and they will need to move into that space for physical exam. Entering the personal or intimate zone too quickly or without notice may be threatening or uncomfortable for many patients.

Connection is facilitated by an open posture, facing the patient or at a slight angle with arms uncrossed. If using the EHR, at least the first minute or two of the visit should be spent looking at the patient rather than the computer. Sitting upright or leaning forward slightly can indicate interest.

Touch

Touch can convey care, concern and emotional support but should be used thoughtfully. Touch on the arm or shoulder is comfortable for most people, while touch on the knee may be appreciated by some and unwelcome for others. In a study in Pakistan, 88% of men and 74% of women appreciated touch as a gesture of respect, empathy, or healing.  Three-quarters of respondents were comfortable and only 1% were uncomfortable with touch on the shoulder. In contrast, the majority was uncomfortable with touch on the knee.

Rapport

Rapport can be defined as a harmonious relationship and relates to collaboration and partnership between patient and physician. Communication strategies that can support rapport include:

• Inviting your patient to share their ideas about what’s going on and their expectations for the visit
• Accepting the legitimacy of your patient’s views even if they don’t align with your own
• Providing support and communicating your willingness to help
• Dealing sensitively with embarrassing topics
• Explaining  the rationale for your questions and physical exam
• Sharing your thinking about what is going on
• Acknowledging emotions and demonstrating empathy

Starting the encounter: Establishing initial rapport

Rapport can be established in the first moments of the encounter.  Knock before entering your patient’s room and ask their permission to come in. Introduce yourself warmly by name, pronouns and role then confirm your patient’s identity with their full name and ask them how they’d like to be addressed.  They may prefer to be addressed formally (Mr. Smith) or informally (Jamie), or they may share a name different from the one in their medical records. If your patient has not suggested that you address them with a gendered title (like Mr. or Ms.) you can avoid mis-gendering them by following up with a phrase like those below.

MS1: “Could you confirm your gender and age for me?“ OR

MS1: “If I refer to you by a title, like ‘Dr.’, ‘Ms.’, or ‘Mr.’ which should I use?” OR

MS1: “Throughout my notes and in discussions with my colleagues, do you have a preference of how you’d like me to refer to you ?”

Once you’ve confirmed your patient’s identity, greet any guests in the room, establish their relationship to the patient and confirm that your patient is comfortable with their presence during the interview and exam. A minute of ‘small talk’ about your patient’s day, occupation or interests can also build an early connection.

Setting the agenda

Collaborative agenda setting is a patient-centered approach to deciding how your time with a patient will be spent. In the clinic, it starts with eliciting the complete list of concerns that they would like to address. The clinician then adds any other issues they feel are important before patient and physician together decide what to cover.  This is an important skill, and we’ll spend more time on it before you start in your primary care clinic.

1. Indicate the time available. “We have about 20 minutes together today.”
2. Forecast what you would like to have happen. “I know you want to talk about the shoulder pain you’ve been having, and I want to follow up on your blood pressure.”
3. Elicit other concerns that your patient would like to discuss. “What else would you like to discuss today?“
4. Confirm the list of concerns and screen for other issues, like need for medication refills, forms filled, etc.
5. Decide together how to spend the visit, taking into consideration the patient and physician needs.

For hospital tutorials, the process will look a little different but you should still set an agenda to orient your patient to the interview process.

1. Indicate the time available. “I have about an hour and a half to spend with you.”
2. Forecast what you would like to have happen. “I’d like to hear about the shortness of breath that brought you in to the hospital, then get a complete picture of your health history and perform an exam of your head and neck, heart, lungs, abdomen, nerves and muscles. Does that sound ok?”
3. Elicit other concerns. “Is there anything else happening this morning? Tests or consultations? Anything else I should know?”

Discussing confidentiality and confirming consent

For hospital tutorials, let your patient know that we are not part of their healthcare team and will not share information with their physicians  team or write in their chart. The only exception is if they are thinking of harming themselves or someone else. Should a patient ever report this to you, discuss it with your mentor immediately.

“I’m not part of your team, and I won’t share any information with your team or in your medical record. The only exception is if you tell me that you are considering harming yourself or someone else – I would need to tell your doctor about that.”

This can be simple – just ask your patient if all of this sounds ok. Your mentors and patient interview coordinators have already gone through a more formal process of describing what will happen and obtaining each patient’s consent. If your patient expresses reluctance or has concerns, check in with your mentor on how to proceed.

Emotions and empathy

Emotions are present in most clinical encounters. Patients’ worry, relief, joy, frustration and other feelings can be expressed verbally or non-verbally, more often with subtle and indirect ‘cues’ than with direct statements. Recognizing these emotions helps to build connection and trust in the physician-patient relationship. Emotions can also serve as useful data in understanding a patient’s perspective, context, hopes and fears.

Clinicians often overlook opportunities to demonstrate empathy, making patients feel that they haven’t been heard even though their words have been registered. It can also be tempting to try to “fix” negative emotions, by encouraging someone who is disappointed or reassuring someone who is fearful, but this can also make people feel they haven’t really been heard. An empathic response is a better alternative.

Empathy is the capacity to understand and relate to the patient’s illness experience, emotions and feelings, and can be expressed in many ways. A nonverbal expression of empathy can be as simple as respectful silence, offering a tissue, or if culturally appropriate, placing a hand on the patient’s shoulder. A statement or question can also acknowledge the emotion and explore it in more depth

PEARLS

The PEARLS framework for demonstrating empathy suggests different types of responses to patient emotion: Partnership, Empathy, Apology or Acknowledgment, Respect, Legitimization and Support. The graphic below provides examples for each.

As you learn to communicate with patients, mnemonics and frameworks like PEARLS can be a good starting point. Communication with patients is not ‘one size fits all’ – the suggested phrases above would feel natural to some physicians and inauthentic for others. Try them out and over time you will build an approach that feels authentic and genuine for you.

In your first interviews, it may be quite difficult to balance collecting medical information and attending to emotion.  Don’t worry – as you gain comfort with the content and process of the interview, you’ll have more and more cognitive space to respond empathetically.

References and resources

Khan FH, Hanif R, Tabassum R, Qidwai W, Nanji K. Patient Attitudes towards Physician Nonverbal Behaviors during Consultancy: Result from a Developing Country. ISRN Family Med. 2014 Feb 4;2014:473654. doi: 10.1155/2014/473654. PMID: 24977140; PMCID: PMC4041264.

https://www.hse.ie/eng/about/our-health-service/healthcare-communication/nonverbal-communication/nhcp-nonverbal-skillscard.pdButt MF.

Approaches to building rapport with patients. Clin Med (Lond). 2021 Nov;21(6):e662-e663. doi: 10.7861/clinmed.2021-0264. Epub 2021 Oct 12. PMID: 34642167; PMCID: PMC8806294.