UDM Solutions

4 No-Cost Ways to Break Down the Patient-Clinician Communication Time Barrier

Open and thorough patient-clinician communication is important both for efficacy of treatment and efficiency of office visits. Certain barriers can impede this. For patients, these barriers may be psychosocial factors such as personality, beliefs, socio-economic status and/or conceptions about their treatment. Additionally, patients can underestimate their own importance in the outcome of their pharmacotherapy. While certain psychosocial dynamics can also be a factor for clinicians, a commonly cited communication barrier is a lack of time. Studies and research have sought to address these issues in communication by developing methods to improve the clinician-patient relationship. By incorporating these methods with the use of laboratory diagnostics, medical history and pharmacogenetic data, clinicians are able to enhance the quality and efficiency of health care through more accurate diagnostics, improved patient adherence, increased patient satisfaction and decreased malpractice litigations.

Some patients may refrain from openly communicating with their clinicians out of fear that they will be perceived negatively. As demonstrated my blog entitled “Real-Life Opportunities to Improve Pharmacotherapy,” patients may endure needless pain because they do not want to “upset” anyone or be viewed as “a difficult patient.” Patients should understand that by telling us how they are responding to treatment they are contributing in a proactive manner that is important to individualize and improve their pharmacotherapy. The following ideas may help us to portray this to patients:

1. Build Trust and Encourage Open Communication: According to a comprehensive review of studies on patient-clinician communication and relationships, “A warm greeting, eye contact, a brief non-medical interaction, or checking on an important life event can build rapport in less than 1 minute.”¹ These gestures improve the course of treatment for both clinician and patient by developing a mutually beneficial relationship; and, they require virtually no additional time the office visit.
2. Understand Patients as Individuals: Empathizing with our patients’ concerns about their treatments and understanding them as individuals allows us to take into account what psychosocial factors may be affecting their pharmacotherapy. This in turn improves our ability to create a pharmacotherapy that is specific to them, enhancing its efficacy and reducing the need for future adjustments.
3. Ensure that Patients Understand Their Treatment: Clinicians can take a preventative approach to improving adherence by eliminating confusion (e.g., complex regimens) and helping patients understand all aspects of their treatment. Opening up this dialogue also aides in creating an environment where patients can candidly discuss any other factors affecting adherence.
4. Offer Suggestions to Improve Communication: As clinicians, we can also offer patients suggestions to improve communication, such as writing down their questions before they come to their office visit. This helps assure that all of their concerns are addressed, reiterates the importance of their active role in their treatment, and ensures that the office visit is utilized most effectively.

Better communication leads to better treatment, and neither requires any extra time. In effect, establishing an open and communicative patient-clinician relationship can save future time spent adjusting and making changes from miscommunication or factors affecting adherence that could have been addressed if communicated initially. Psychosocial factors or concerns about how their clinician perceives them may inhibit some patients from openly communicating with their clinician. Alleviating these concerns can help to create an environment where patients feel comfortable disclosing all information pertinent to their pharmacotherapy and can help patients to understand the importance of doing so. Employing empathy and education strengthens the patient-clinician relationship and results in better treatment and more satisfied patients. Patient satisfaction has been shown to decrease malpractice litigations. Information provided by patients regarding the effects of their treatment can be used with laboratory diagnostics, medical history and pharmacogenetic data to further individualize pharmacotherapy and improve the quality of health care.

1. Roxanne Nelson and Charles Vega MD, Improving Communication Skills Enhances Efficiency and Patient-Clinician Relationship. Medscape Medical News 2008.

Real-Life Opportunities to Improve Pharmacotherapy

My friend, who is in her eighties, was recently hospitalized for back surgery and then stayed at a nursing home/rehabilitation center after her hospital discharge. Both in the hospital and in the nursing/rehabilitation facility, she was under-treated for her pain. In the hospital, she was prescribed hydrocodone as needed (PRN) and morphine around the clock (ATC). She was not being administered her morphine ATC and was mostly being administered hydrocodone which did not alleviate her pain. Only after I spoke with her clinicians did she receive her morphine as ordered. Even then, her morphine dose would be administered late, leaving her in pain during the intermediate time interval.

When I visited her at the nursing home, a mutual friend informed me that although she was in extreme pain, she did not want to "upset" anybody and was reluctant to inform her physician of her pain. Her prescription regimen was for oxycodone every eight hours PRN, and she would have to ask her nurse for the pain medication every time. With this regimen, she experienced pain during the entire 3-4 hours prior to her next dose. I told her that I would speak to her physician to review her pain medication. At first, she was extremely anxious because she feared she would be perceived as a difficult patient. Later, however, she thanked me. After communicating with her clinicians, she was ordered a slightly lower dose of oxycodone every four hours ATC. This helped better control her pain and contribute to a better quality of life during the post surgical period.

In both my personal and professional experience, it is extremely common that patients are prescribed generic medication regimens that are not individualized for their specific needs compounded by an ineffective follow-through by practitioners for optimizing patient pharmacotherapy. My personal friends and family have been affected by this type of healthcare standard that currently exists. As clinicians, we need to transform the subjective and generic dynamic in which we select, prescribe and monitor medication regimens, especially for our elderly patients, and create a scientific standard founded on objectifying their pharmacotherapy.

If my friend had undergone clinically relevant genetic testing, especially cytochrome P450 (CYP450) 2D6 testing, her team could have obtained objective data to assist in optimizing her pain medication regimen at the initiation of treatment. As a clinician, I wanted to know her CYP2D6 metabolism prior to making my recommendations to her team. In addition, we need to create the environment, communication tools and time needed to help enhance communication with our patients. We need to take into account the various psycho-social and biological factors that can impede our ability to individualize treatment. My friend could have been assigned a regimen that was individualized for her. Instead, she endured weeks of pain until her final regimen adjustment. This situation was worsened by a breakdown in communication and follow through between my friend and those responsible for her care. We need to improve our patients' pharmacotherapy and safety by implementing these tools as the standard of care, especially in our elderly population.

Fortunately, my friend has since recovered from her post surgical pain and is doing well.