PATiENT EduCATiON
ANd COUNSEhNq
ELSEVIER
Patient
Education
and Counseling
23 (1994) 131-140
A new model for physician-patient
Vaughn
communication
F. Keller *, J. Gregory
Carroll
Miles Insiifure for Health Care Communication, 400 Morgan Lane. West Haven, CT 06516, USA
Received
21 July 1992; accepted
27 February
1994
Abstract
The E4 model for
model. Derived from
to be a useful tool in
Information on how
Keywords:
physician-patient
communication
is presented with specific techniques for implementing
the
an extensive review of the literature on physician-patient
communication,
the model has proved
workshops for and coaching of physicians regardless of specialty, experience or practice setting.
to obtain descriptive materials about the workshop and an annotated bibliography is included.
Communication;
Physician-patient
relationships:
1. Introduction
The scholarly discussion of physician-patient
communication reflects three distinct, although
related, perspectives on the topic. Each perspective
makes a unique contribution to the discussion (see
Fig. 1).
The first perspective addresses core beliefs, the
philosophy of the physician. It views the physician-patient relationship as a consequence of the
physician’s central understanding of the processes
of disease and healing. Historically, the dominant
construct taught in medical schools has been
reductionistic. The healing process has been construed as one in which a physician gathers data
about the anatomy, physiology and symptoms of
* Corresponding author.
0738-3991/94/$07.00
0 1994 Elsevier Science Ireland
SSDI 0738-3991(94)00631-U
Adherence;
Empathy
the patient, constructs a differential diagnosis,
determines a treatment plan, and manages the
patient in light of that plan. In 1977 Engel
challenged this paradigm [ 11. He issued a call for
physicians to view disease and healing as open system processes. In this new paradigm the patient
becomes a systemic creature with permeable boundaries (mind/body; organism/environment) rather
than a complex of isolated symptoms and physical
features. In Engel’s approach, mind, body and
environment are no longer separated. While
Engel’s biopsychosocial model of disease and healing has received significant attention in primary
care as an idea, it has received less attention as a
guide for physician behavior. Mishler, for example, finds that physicians and patients speak and
think about health from very different orientations. Mishler calls these orientations the voice of
medicine and the voice of the life world [2].
Ltd. All rights reserved
132
V. F. Keller,
J.G.
Carroll/
Patient
THREE PERSPECTIVES
PHILOSOPHY
communication
BEHAVIOR
Psychology of Physician
Skills Repertoire of Physician
Fig.
1.Three perspectives on physician-patient
communication.
The second perspective views the physicianpatient relationship as a consequence of the roles
that each party enacts towards one another. For
instance, Emanuel and Emanuel have written
about four role possibilities for the physician to
enact: paternalistic, informative, interpretive, and
deliberative [3]. Clearly the nature of the relationship and the resulting communication behavior
will change depending upon the role position that
the physician takes. Similarly, patients may enact
different roles. Some investigators have trained patients to become more assertive in interacting with
their health care providers [4,5].
Role enactment is a complex process that has
ethical consequences since a role both proscribes
and prescribes specific behaviors [6]. Consequently, how and what one says in a dialogue is, in part,
role determined.
The third perspective views the physicianpatient relationship as a consequence of how
physician and patient behave towards one another
at a verbal level. Two factors have been identified
as critical to the physician’s contribution to the
difficulties and
dialogue: the psychological
strengths that the physician brings to this intimate
interaction, and the communication skills repertoire of the physician.
Psychiatric concepts of transference
and
counter-transference have been investigated as a
method for understanding both the what and the
Educ.
Couns. 23 (1994)
131-140
why of physician communication behaviors [7].
Small groups called Balint groups are used in some
settings to provide physicians with an opportunity
to explore the psychological stimuli present in the
physician-patient
encounter. Similarly, direct
educational approaches have been used to increase
the repertoire of responses available to physicians
as they interact with patients (81.
It is our belief that any approach to enhancing
the physician-patient relationship must account
for all three of these perspectives. We understand
this to be a necessary context if one is to avoid the
conceptual pitfalls inherent in an atomistic view of
physician-patient communication.
Beginning, then, with a consideration of illness
and healing, we agree with the paradigm that views
both illness and healing as complex phenomena
that encompass multiple causalities: physical,
psychological, familial, communal, cultural, and
environmental. Because of these multiple causalities, the amount and kind of information required
to understand an illness episode is extensive. Obtaining this information is not always easy as
Mishler has demonstrated [2]. The behavioral
model which we will present accounts for the complexity of the data gathering and processing tasks
inherent in the biopsychosocial paradigm of illness
and healing.
Although we refer to the physician-patient
dialogue, we use it is an abbreviation. We view the
patient as a member of an extended intimate system which includes family members, friends and
workmates. We view this intimate system as a contributing force to both illness and healing. This
view goes far beyond simply including family
members in patient visits on occasion: it is a way
of thinking about illness and healing [9]. Because
of this perspective, we see the physician as always
relating to a patient system regardless of who the
physician is talking to at a given time.
Second, our understanding of the role relationship between physician and patient is one that
allows for multiple roles for physician and patient
but uses as its center point a relationship of partnership and collaboration. We acknowledge that
there are times when it is inappropriate and ineffective to collaborate with patients because of
patient desires for autonomy or dependence or
133
V.F. Keller, J.G. Carroll/ Patient Educ. Couns. 23 (1994) 131-140
because of a patient’s
ability physical
or
psychological - to enter into a collaborative
relationship [lo]. However, the role relationship
we
propose uses collaboration
and partnership as the
‘default’ mode.
In staking out this position we are consciously
rejecting both the autocratic
and informative
models as default stances. We believe it is inappropriate and ineffective for a physician
to continuously function as a parent infantalizing
his/her
patient or as an uninvolved
newscaster reporting
information
to an audience. Both Lipp [l l] and
Katz [6] have written eloquently about the dilemmas of the physician in establishing a role relationship that is rooted in ethical concerns for dignity,
respect, and healing. However brief the encounter,
we view the physician-patient
relationship
as a
process of role enactment in which ethical issues
are always present.
Finally we see the physician-patient
relationship as bounded by the potential of each party to
interact with the other. However, the physician, as
the professional
who assumes responsibility
for
delivering a service, has a unique responsibility
for
developing
and enhancing
the relationship.
We
believe that the physician’s potential to interact
effectively with the patient is constrained
by two
phenomena.
Both phenomena
allow for growth
strategies.
First, we believe it is useful for a physician to
understand his or her own psychological responses
to a patient, and this can be done most readily
when the physician has available to him or her self
both the historical antecedents
of the physician’s
psychological responses, and an awareness of current stresses that are influencing the physician’s interaction
with the patient. This understanding
does not, in and of itself, provide the physician
with a repertoire
of effective responses to the
varieties
of patient
situations
that
present
themselves. We believe, therefore, that it is also
important for the physician to consciously develop
a repertoire of effective communication
strategies
that are personalized through practice and subject
to adaptation
through feedback.
It is possible, then, to enhance the physicianpatient dialogue from many perspectives
which
can be labeled philosophical,
role taking, and
behavioral. Within the behavioral perspective we
include concerns for the physician’s psychological
responses to the patient as well as the skills repertoire possessed by the physician [12]. We believe
there is merit in, and necessity for, all three
perspectives.
Because of our institute’s organizational
mission
to provide continuing
educational
opportunities
for practicing physicians in brief workshops, our
specific interest has been in the pursuit of a behavioral approach that develops a core repertoire of
effective communication
strategies.
One model for the development of a behavioral
repertoire has been proposed by Bird and CohenCole. This model has been used in workshops
sponsored by the American Academy on Physician
and Patient and serves as the basis for CohenCole’s book on the medical interview [ 131. The
model posits that the medical interview has three
functions: ‘(a) gathering data to understand
the
patient; (b) development
of rapport and responding to the patient’s emotions;
and (c) patient
education and behavioral management’ (p. 378 in
Ref. [12]).
Originally developed as a teaching model, the
Bird and Cohen-Cole approach has served us as a
point of departure with which to explore our own
thinking
about the physician-patient
dialogue
from a behavioral perspective. We believe that the
three-function
approach can be improved upon
and have sought to do so in the model that is
offered below. Although the model is behavioral in
nature, it is informed by the philosophical and role
taking perspectives in which we believe.
2. A model for physician-patient
communication
The recent history of the healing arts has emphasized the role of the physician as a discoverer
and identifier of pathology and as an agent of
healing. More simply, the role has been to find a
problem and fix it (see Fig. 2). When fixing the
problem was beyond the power of medicine, the
task was to ease the patient’s suffering and/or
minimize
any dangerous
outcomes
if at all
possible.
As was mentioned above, with the questioning
of this ‘find it and fix it’ role definition as overly
V.F. Keller, J.G. Carroll/ Patient Educ. Couns. 23 (1994) 131-140
134
Biomedical
Tasks
Communication
Tasks
Find It
Engage
/
b
Fix It
--;’
Fig. 2. Biomedical tasks.
narrow, and too focused on pathophysiology, a
new paradigm of disease and healing has emerged
which accounts for the psychological, sociological,
and behavioral forces that are always present. This
expanded context has focused attention on the
medical interview, and the transactions that occur
during the interview, as an area for change. The
following model for physician-patient communication presents specific communication strategies
to be used in the interview.
The model was developed from an extensive review of the literature on physician-patient communication and has been tested in more than 500
workshops conducted for over 8000 practicing
physicians from every specialty and region of the
USA during the years 1989- 1994.
2.1. Four communication tasks
Four communication or relationship tasks must
be performed during the medical encounter (see
Fig. 3). Each of these tasks requires specific skills.
While presented in a sequential manner, these
tasks are not performed sequentially. In fact, they
recycle during the progress of the encounter. These
tasks do not replace or compete with the tasks of
Fig. 3. Communication tasks.
finding and fixing the problem. Instead, they make
it possible to perform the traditional tasks more
successfully, while contributing to a more complete approach to the long-term well-being of the
patient (see Fig. 4).
Since the four elements of the model begin with
the letter ‘E,’ we have dubbed it the ‘E4’ component of clinical care. It serves as a complement to
the ‘find it and fix it component’ or F2.
3. Engage the patient
For a successful encounter to occur, there must
be a human engagement. Information and meaning exchange will only take place if the patient and
physician are actively engaged in the communication process. The physician can do several things
to facilitate this.
First, the physician can accept and utilize the
knowledge that the thought and articulation process of the physician and patient are essentially different. The physician has a unique vocabulary
which has been mastered through years of schooling (some estimates are that a physician learns
13 000 new words during the training process). In
V.F. Keller. J.G. Carroll/ Patient Educ. Cows. 23 (1994)
Complete Clinical Care
Fix It
/
Fig. 4. Complete
clinical care.
addition,
the physician’s
way of thinking
and
problem solving is also learned. Diagnostically,
the decision
tree dominates
the physician’s
thinking.
The patient, on the other hand, has an experience of illness which includes
lifestyle consequences, fears, and altered roles. The patient does
not know the language or the thought process of
the physician. However, the patient is the only one
who knows and understands
the personal story of
the illness. This story must, and will, come out as
a narrative rather than a scientific outline [2].
The task, for the physician,
is to elicit and
understand the story. Specific techniques help this
happen. The physician can encourage the patient
to tell the story in his/her own words [ 141.
Specifically inviting the patient to tell the story
and supporting the patient while the story is being
told will facilitate this process. This does not mean
that the decision tree will not be used. However,
thinking of the first two to three minutes of the interview as the patient’s time to tell the story in an
uninterrupted
manner
is useful. Unfortunately,
observation
research indicates that the average
131-140
135
physician interrupts the patient narrative for the
first time after only eighteen seconds [15].
Second, the physician can discover all of the
complaints. This is especially necessary in primary
care settings. Just as most of us do not go off to
the cleaners with one garment, most patients do
not come to the office with one complaint. Three
is more typical. Rarely do patients know how
much time the physician has budgeted for a visit.
The first complaint presented may not be the
most critical one. It is important
to engage the
patient in such a way that all complaints
can be
elicited and then prioritized [ 151. Clearly, all complaints will not be addressed in one encounter.
However, after the complaints
have been elicited
the patient can be asked, ‘What were you hoping
we would accomplish
today?’ Physician
and
patient can then discuss and agree upon priorities.
Without this process, major complaints may be
mentioned at the end of the encounter, literally as
the patient or physician is about to leave the room.
Following are specific strategies for engagement.
3.1. Join the patient
Joining takes place during the opening minutes
of the encounter. With a new patient, joining takes
more time than with a returning patient. The exception to this sequence is an emergency in which
the biomedical tasks must dominate.
Even in an
emergency, introductions
are important.
Communicate
warmth and welcome. Welcome
the patient to your setting. It is not unlike being a
host or hostess. Introduce yourself and others.
Be curious about who the person is as a person
rather than their medical problem.
Find some
common experience, background,
or identity on
which the two of you can establish some similarity
(comfort and trust). Joining goes beyond discussing the weather and parking.
It is more than
establishing rapport.
Listen to the language of the patient and adapt
your language system to meet theirs. It is easiest to
listen for key words and to use those words.
3.2. Elicit the agenda and the story
Invite the patient to tell the story of the illness.
The story is told throughout
the joining and during the presentation
of complaints. Sometimes it is
136
V.F. Keller, J.G. Carroll/ Patient Educ.
told after the agenda is set. It must be heard. The
first few minutes of the interview is the ‘patient’s
time’. This is time to inhale information rather
than to organize it.
Use open ended questions. ‘I’m curious about.’
‘Tell me more about.’ Avoid the ‘wh’ questions
(when, what, why, where, etc.) during the early
stages of the interview. Avoid questions that can
be answered with one word.
Acknowledge the story. Do not simply say,
‘urn’. Use responses that communicate your interest: ‘That must have been uncomfortable’.
Communicate interest physically by leaning
towards the patient and looking at the patient.
Monitor time. Monitor time at first to make
sure you are giving the initial few minutes to the
patient to tell his or her story. One physician
trained himself by using a silent egg timer. At first
he was shocked by his urge to interrupt.
3.3. Set the agenda
Do not assume you know why the patient is
there. Even when you suspect why the patient has
come, you probably do not know the entire story.
The task is to establish an agreed upon agenda.
Find out all the complaints. Assume there is
more than one. Ask for all of them: ‘Anything else
on your mind?’ ‘What else has been happening?’
‘Anything else you are wondering about?’ If the
physician does not learn all of the complaints, she
or he is not in a position to discuss with the patient
what is most critical. It also leads to the ‘door
knob’ complaint: ‘By the way doctor . . . .’
Find out the patient’s expectation or goal for
the visit. This may differ from the presenting complaint. At times it is as simple as getting a form
signed. Frequently, gaining reassurance is the
patient’s goal.
Agree upon the agenda. It may be necessary to
schedule another visit for complaints of less urgency or complaints requiring more time. One physician calls this ‘referring to myself.’ The physician
is not passive in establishing the agenda. It is a
negotiated process.
4. Empathize with the patient
Physicians recognize the medical care they
would like for themselves. When they are asked to
Couns.
23 (1994)
131-140
describe personal episodes in which they experienced or observed excellent health care, they
inevitably mention two things. First, the physician
providing care was technically excellent; second,
the physician was empathic and present to the
patient as a human being.
Empathy is not a genetic trait; it can be learned
[ 161.It is an active concern for and curiosity about
the emotions, values, and experiences of another
[ 171. Again, several specific actions are useful.
First, the physician can demonstrate awareness
that the patient has feelings and values. Noticing
and commenting upon what the physician sees and
hears from the patient communicates this awareness. Emotions and values are communicated nonverbally as well as verbally. Literally, the physician
sees and hears the patient and lets the patient
know what is seen and heard.
Second, it is important to accept the feelings and
values of the patient. Let the patient know that not
only are these feelings and values seen and heard,
but they are acceptable and, at times, valuable to
the physician. Sometimes self-disclosure is an appropriate method for communicating that feelings
and values are appropriate topics for discussion.
Third, empathy conveys an impression that the
physician is ‘present’ and ‘with’ the patient. The
opposite of being ‘present’ and ‘with’ is easier to
describe. Spiro et al. refer to the physician’s distance as the physician’s communication
of
equanimity rather than empathy [17]. Or, the
physician is distracted by other activities. The
physician avoids eye contact, has a blank stare, or
allows frequent interruptions: telephone calls,
nurse’s questions. Being ‘present’ and ‘with’ requires attention, curiosity, and sincere interest in
the world of the patient. The following techniques
support the communication of empathy.
4.1. The setting
The non-verbal posture and physical setting of
the visit facilitate or frustrate an empathic connection. Some practices are simple to initiate.
Greet a new patient while they are fully clothed.
This need only take seconds. It is not as important
for returning patients as it is for new patients. It
can be as simple as stopping in the examination
room for a few seconds and saying, ‘Hello, I am Dr
X. I’ll be with you in a few minutes. The nurse will
V.F. Keller. J.G. Carroll/ Patient Educ. Couns. 23 (1994)
show you where a gown is and where you can put
your clothes’ (if appropriate).
Do not write and listen at the same time. Alternate. When listening and questioning,
look at the
patient. It is more time effective to alternate listening and writing than trying to do them simultaneously. When a physician writes while a patient
is speaking, the physician does not hear all that a
patient has said and subsequently
asks questions
that the patient has already answered but the
physician did not hear because he or she was busy
writing.
Sit or stand relative to the patient so that head
level is approximately
even. (This does not pertain
to all parts of the physical examination.)
Unequal
height conveys dominance.
It is a very primitive
phenomenon
and communicates
being ‘above’ the
other. It detracts from establishing a physical situation in which empathy is facilitated.
Do not permit physical barriers to come between you and your patient. Two that stand out
are (a) the chart, (b) the desk. Come from behind
the desk so you can sit face to face with the
patient. Do not bury your head in the chart.
Videotapes
of hospital
physician-patient
visits
reveal frequent instances of physician visits with
the chart rather than with the patient.
4.2. Create a setting that is psychologically safe
Several verbal behaviors
contribute
to establishing an empathic
connection.
Awareness
of
psychological
safety is important.
Safety exists
when we feel welcome, valued, and accepted.
Invite a patient to tell you what she/he is feeling
or thinking. Be curious about the total experience
of the patient as a person who has feelings, values
and thoughts.
Acknowledge feelings, values and thoughts. Do
not evaluate them. ‘I understand
that you are
scared at the thought of surgery. Lets talk more
about it’; not, ‘There’s no reason to be scared’.
Notice facial expressions.
While facial expressions communicate
feelings, you cannot always be
sure what feelings are being communicated.
Noticing and commenting,
however, often gives the
patient permission to report the feelings. ‘I see you
frown when I mention exercise.’
Use self-disclosure
when appropriate.
Do not
tell the patient your life story. Do share something
131-140
of your life when you believe it will facilitate
patient’s well-being.
13-l
the
5. Educate the patient
Education is a complicated
process. A patient
will frequently have questions which the patient
will not ask or which will occur to the patient only
after he or she has left the offtce. Patients have different desires for information.
This raises a
perplexing dilemma because of the need for informed consent.
One position is to assume that most patients
want answers to questions about (a) diagnosis, (b)
etiology, (c) treatment, (d) prognosis, and (e) functional consequences
(impact on lifestyle). The
education task is to answer these questions during
the course of the visit.
There are also questions that certain specialties
can expect. For example, geriatricians,
obstetricians and pediatricians
are consistently
asked
questions that have a sub-text of, ‘Am I doing the
right thing?’ The role of ‘care giver’ to a patient
(e.g. a child or parent) brings about a unique anxiety and consequently
a different kind of questioning.
Patients do not come into the medical encounter
as blank slates. Typically they have already talked
to someone about what is taking place with them.
They may have read something about what they
believe their condition
to be. Education
is not
simply giving information.
It requires understanding the cognitive, emotional, and value perspectives of the patient. It includes the struggles of the
patient to respond to the illness and the health care
system. To accomplish
this, the physician must
discover what the patient knows and how the
patient is thinking
and feeling about whatever
knowledge he or she possesses. The only way to
accomplish this is to ask.
Thus, patients both want information
and have
information.
Patients may have an incomplete or
different map of reality, but they have some map.
The physician’s educational
task is to explore the
map and present the physician’s view of the situation. However, it is the patient’s map that is central and will impact patient behavior,
not the
physician’s map. The patient may have functional
questions that seem trivial to the physician. For
138
V.F. Keller, J.G. Carroll/ Patient Educ. Couns. 23 (1994)
example, ‘Do I have to stop working on the night
shift?’ The question, though, may reflect a difficult
reality for the patient: ‘I get an important pay differential by working on the night shift, but I’ve
been doing it for live years now and would like to
have a reason my family would accept for changing shifts and making less money’.
The following outline can be useful.
5.1. Assess the patients understanding
Under customary circumstances, patients will
forget 50% of what the physician says the minute
they walk out the door. It is important to provide
information that fills in gaps and is important to
the patient’s health care questions. Find out what
the patient knows. Find out how the patient
understands the situation and what is to take
place. There are only two ways of discovering the
patient’s map: listening carefully to the talk of the
patient, and asking specific questions.
Ask for questions and things they wonder
about. Not all patients will ask questions or tell
you what they wonder about (anxieties) without
being prompted. The statement, ‘Is there anything
else that you have been thinking or wondering
about’, is more open ended than, ‘Any questions?’
5.2. Assume questions
Patients have questions. They do not always ask
them. You can assume they are present. We
believe the following eight questions are present in
most situations. Consequently, it is useful to
develop a protocol for answering them with the
same regularity that one asks standard diagnostic
questions.
Answer questions about their situation. Assume
they want to know:
(1)
(2)
(3)
What has happened to me?
Why has it happened to me?
What is going to happen to me, in the shortterm, in the long-term?
Answer questions about your actions. Assume
they want to know:
(1)
What are you doing to me (examination,
tests)?
(2)
(3)
(4)
(5)
131-140
Why are you doing this rather than something else (diagnostic or treatment options)?
Will it hurt me or harm me, for how long,
and how much (diagnostic and treatment)?
When and how will you know what these
tests mean?
When and how will I know what these tests
mean?
5.3. Assure understanding
Providing
information
(teaching)
is not
educating. Education does not take place until the
patient is able to utilize the information in an
effective manner. Assuring understanding is an
active process.
Ask if the patient wants answers to additional
questions. Give permission to ask. There are not
always answers. It is useful, therefore, to engage
around the issue of answers: ‘Are there other
answers that you need’, ‘What information would
be useful to you at this time?’ Sometimes this will
surface the patient’s frustration at the lack of
answers or strong reactions to the information he
or she did receive.
Ask what or how they understand. Discover
whether or not the patient understands everything
you believe it is important for him/her to understand. Do not ask if they understand. A simple
way of doing this is to acknowledge your own
fallibility: ‘I know that I forget to mention things
at times. So, would you tell me what your understanding is at this point so I am sure we are on the
same wavelength and I haven’t forgotten
anything.’
6. Enlistment
Enlistment involves two processes, decision
making and encouraging adherence, that have the
same goal: increasing a patient’s responsibility and
competence to care for his or her own health.
6.1. Decision making
The first process is that of decision making. A
change in the role relationship between physician
and patient has developed over the years. The language used by medical settings reflects both the old
and new understanding of the role relationship.
V.F. Keller, J.G. Carroll/ Patient Fduc. Couns. 23 (1994)
For example, ‘doctor’s orders’ and ‘patient management’ reflect role definitions that assigned all
power to the physician. By contrast, ‘informed
consent’ and ‘advanced directives’ reflect the power of the patient to self-determination, to make
decisions about his/her health care.
It is insuflicient to believe that patients should
become involved in making decisions about their
health care. Just as physicians struggle with the
new role alignments, so do patients. Some patients
will say, ‘I’ll do whatever you tell me to’, or, ‘I’ll
do what you think is best’. Consequently, the
physician frequently has to take an active role in
enlisting the patient in the decision making process
[6]. This might include (a) asking the patient about
his/her own thoughts about diagnosis and treatment, and (b) clarifying that the physician wants
the patient and the physician to think through and
reach agreement about critical issues as a collaborative process.
Most patients make a self-diagnosis. It is human
nature to do so. If your diagnosis and the patient’s
differ, the patient will act based upon his or her
own diagnosis. Consequently, it is imperative that
and discuss the patient’s
You understand
diagnosis.
Ask for the self-diagnosis! One researcher suggests the formulation: ‘I’ve arrived at one explanation of what the difficulty is [provide your
explanation]. How does that lit in with what you
have been thinking?’ [18].
Listen to, but do not evaluate, the input of
others. Be careful not to evaluate the diagnostic
suggestions that have been made to the patient by
others: spouses, friends, relatives, magazines, or
other physicians. Discovering a different opinion
is common. Since you cannot determine the veracity of the patient’s report of conversations with
others, and you do not know the nature of their relationship to the third party, it is best to maintain
a completely neutral position. By contrast, a cardiologist recently told his patient who had asked
questions about the Dean Ornish cardiac care program, ‘Only a psychotic would follow that diet’.
Strive for agreement. Patients frequently have
preferences for treatment. This will influence how
they think about diagnosis. They may favor a diagnosis because they favor the treatment associated
131-140
139
with that diagnosis. Consequently the physician
must be sensitive to the manner in which the
patient brings diagnosis and treatment together.
Agreement about a diagnosis improves the
likelihood that the treatment will be adhered to.
Time spent in discussion bringing about agreement
regarding diagnosis is time well-spent.
6.2. Adherence
The second enlistment process involves adherence to an agreed upon regimen. The research on
adherence, the term currently used to replace
‘compliance’, indicates that roughly fifty percent
of the time patients do not adhere to their physician’s recommendations [19]. It is important to
note that physicians are not good at predicting
who will and will not adhere to a therapeutic
regimen. It is also important to note that the
patient characteristics that physicians believe influence adherence, do not: sex, socio-economic
status, age, etc.
It is important for the physician to take an active role in enlisting the patient in the healing process. Research has shown that six specific actions
will increase the likelihood of adherence.
(1) Keep the regimen simple. The fewer the required behaviors, the more likely it is that the
regimen will be adhered to. Complicated regimens
can often be better implemented if they are broken
down into sequential steps.
(2) Write out the regimen for the patient. Much
of what a physician says is forgotten the moment
the patient leaves the encounter. If pre-printed
forms are used, underlining and personalizing the
form in any way possible will help.
(3) Motivate the patient and give specifics about
benefits and timetable. Too frequently patients are
not sure why they are doing what they have been
asked to do and do not know when they will experience benefits.
(4) Prepare the patient for side-effects and for
optional courses of action. This is more than a
matter of informed consent. Unanticipated sideeffects are much more likely to interfere with a
patient’s adherence than those that are anticipated.
(5) Discuss with the patient any obstacles to
moving forward with the regimen. What will keep
140
V.F. Keller, J.G. Carroll/ Patient Educ. Couns. 23 (1994)
the patient from following through? Develop
strategies for overcoming these barriers.
(6) Get feedback from the patient. It is important for the physician to be assured that the patient
understands the regimen. To accomplish this,
physicians can ask the patient to state what the
patient understands he or she will do. It is also important to ask about adherence to the regimen
during subsequent visits. In addition, it is important to discuss how the patient feels about following the regimen. Emotionally, are they committed
or reluctant?
Enlistment is an active process in which the
physician deliberately sets out to establish a health
partnership. It begins, however, with the concept
that the patient has already thought about what is
taking place. Finally, then, be sure that you
understand what the patient believes is taking
place and how the situation is affecting his/her life.
8. References
1
4
5
6
9
IO
7. Summary
II
We have identified three perspectives that influence the physician-patient relationship and have
taken the position that all three are valid and must
be addressed in understanding what takes place
between physician and patient: the philosophy of
disease and healing held by the physician, the role
that the physician assumes and its ethical consestrategies
quences, and the communication
employed by the physician. The E4 model
above
describes
communication
presented
strategies that are informed by assumptions about
these three perspectives and have proven to be effective through research and clinical experience.
The model has been presented to thousands of
physicians in a half-day interactive workshop on
physician-patient communication for physicians
of all specialties and practice settings throughout
the USA. Evaluations of the workshops, postworkshop focus groups and follow-up surveys of
these physicians months after the completion of
workshops show that the model is judged to be
useful by the physician participants. Currently,
more than two hundred workshops are conducted
throughout the United States each year’.
131-140
12
13
14
15
16
17
18
I9
Engel CL: The need for a new medical model: a challenge
for biomedicine. Science 1977; 196: 126-136.
Mishler EC: The Discourse of Medicine. Norwood, NJ:
Abler Publishing Corporation,
1984.
Emanuel
E, Emanuel
L: Four
models
of the
physician-patient
relationship.
J Am Med Assoc 1992;
267( 16): 222 I-2226.
Greenfield S, Kaplan S, Ware J: Expanding patient involvement in care. Ann Intern Med 1985; 102: 520-528.
Roter D: Patient participation
in the patient-provider
interaction: the effects of question asking on the quality of
interaction,
satisfaction,
and compliance.
Health Educ
Monogr 1977; 5: 281-315.
Katz J: The Silent World of Doctor and Patient, New
York: The Free Press. 1984.
Balint M: The Doctor, His Patient, and the Illness. New
York: International
Universities Press, 1972.
Maiman L, Becker M, Liptak G, Nazarian L. Rounds K:
Improving pediatricians’ compliance-enhancing
practices.
Am J Dis Child 1988; 142: 773-779.
McDaniel S, Campbell T, Seaburn D: Family-oriented
primary care: a manual for medical providers. New York:
Springer-Verlag,
1990.
Steele D, Blackwell B, Gutmann M, Jackson T: The activated patient: dogma, dream, or desideratum.
Patient
Educ Couns 1987; IO: 3-23.
Lipp MR: Respectful Treatment: A Practical Handbook
of Patient Care (2nd edn.). New York: Elsevier, 1986.
Epstein R, Campbell T, Cohen-Cole
S, McWhinney
1.
Smilkstein G: Perspectives on patient-doctor
communication. J Fam Pratt 1993; 37(4): 377-388.
Cohen-Cole
S: The Medical
Interview:
The Threefunction Approach.
St Louis: Mosby Year Book. 1991.
Rowland-Morin
P, Carroll J: Verbal communication
skills and patient satisfaction:
a study of doctor-patient
interviews. Eva] Health Prof 1990; 13: 168-185.
Beckman H, Frankel R: The effect of physician behavior
on the collection of data. Ann Intern Med 1984; 101:
692-696.
Platt F, Keller V: Empathic action: a teachable skill. J
Gen Intern Med (in press).
Spiro H, Curnen M, Peschel E. St. James D. eds. Empathy
and the Practice of Medicine. New Haven: Yale University Press, 1993.
Becker M: Improving
Adherence
[audiotape].
West
Haven CT: Miles Institute For Health Care Communication, 1991.
Meichenbaum
D, Turk D: Facilitating Treatment Adherence: A Practitioner’s
Guidebook.
New York: Plenum
Press, 1987.
‘Information
about the physician-patient
communication
workshop and an annotated bibliography
of the literature on
physician-patient
communication
are available at no cost from
the Miles Institute for Health Care Communication,
400
Morgan Lane, West Haven, CT 06516, USA; Tel. +I (800)
800-5907.