In This Issue: Back to Basics: Talking, Listening, and Low-Tech Primary Care

TALKING WITH AND LISTENING TO PATIENTS

Communication plays a central role in 3 manuscripts in this issue: communication with patients about health risk, communications with family and patients about end-of life-care, and communication with patients with intellectual disabilities. As one of my teachers once reminded me, we may send a signal to someone, but the message they receive depends on the person. Describing cardiovascular risk in a dispassionate and accurate way is a goal for counseling patients about risk, but Goodyear-Smith and colleagues showed that patients prefer to know what their doctor thinks and prefer visual depictions to words; those who prefer words respond to relative risk language better than absolute risk.¹ Knowing the patient, once again, is crucial to choosing the most useful method of counseling and encouraging behavior change.

Women with and without intellectual disabilities may receive the same information about reasons for and risks of mammography, but as Wilkinson and colleagues show, those with intellectual disabilities have very different understandings and get different messages.² The authors show that standard communication really needs to be individualized. As many practices have increasing numbers of patients with such disabilities, clinicians need training and better information about how to work with them to address fears and concerns. When we talk about cultural competence, we also need to include understanding and working with the cultures associated with disabilities.

Do patients increase their risk of a major clinical depression because of developing a chronic illness, or does a preexisting tendency toward depression manifest itself once a chronic illness is encountered? The answer from Naranjo and colleagues is yes!³ Spending time, as they outline, understanding a patient’s history of depression and looking at the patient’s affective response to developing diabetes both increase the likelihood of identifying patients with diabetes whose depression might challenge their ability to adhere to therapeutic guidelines.

Using large national data sets, Do and colleagues describe how well physicians are talking with patients about self-care relating to approaches outlined in the guidelines for managing osteoarthritis.⁴ They found an increase in counseling about weight loss but no changes in counseling about exercise and arthritis care. Unfortunately, advice is just that and says nothing about whether the advice is followed. Increasing use of guidelines to improve patient function begs the need for a new model of delivery of primary care that takes the burden off physicians and places it on teams of care with both expertise and time to work with patients.

Two studies look at measuring patient-centered care, a central value in modern medicine: a systematic review of the instruments currently in use to measure the degree of patient-centeredness in clinical work, and the development of a scale for determining physician trust of patients.^5,6 On one hand, does the patient feel that the clinicians are attending to the patient’s concerns, worries, and needs, and how do we know that? On the other, do clinicians trust what patients are telling them, and how would we measure that? In a review of instruments for patient-centeredness by Hudon and colleagues,⁵ the authors categorize existing measures, finding that all instruments share some core elements. But beneath it all, the feeling of connectedness to a physician is often driven by whether that clinician attends to patients thoughtfully and sensitively over time. The instrument measuring trust of patients⁶ was developed in an environment that is not easily generalizable—a clinic serving patients infected with the human immunodeficiency virus who have a high use of chronic pain medications. A concern for many educators is that students and residents may be quick to mistrust patients because of issues of social and cultural ignorance on the part of the learner. Whether we trust patients who seem more like us and, conversely, mistrust those who are not is an important issue to address early and often. Effective patient care is based on mutual trust. Requiring that patients prove that they are trustworthy while not requiring the same of clinicians is the wrong way to develop a relationship.

In their editorial, Epstein and Street⁷ elaborate on important components of patient-centered care, as well as offer educational and organizational ideas to improve the process. “Training physicians to be more informative, mindful, and empathic” as they put it, is training that should be as rigorous and ongoing as any cognitive or procedural education for family doctors. Despite the wide availability of clinical information for both patients and clinicians, the success of any medical system still rests on the doctor-patient relationship. As McWhinney put it in 1975, “to restore the primacy of the person, one needs a medicine that puts the person in all his wholeness in the center of the stage and does not separate the disease from the man, and the man from his environment.”⁸