In the era of COVID-19, clinicians face myriad new communication challenges: muffling masks; glaring face shields; heightened anxiety and fear amongst patients, families, and clinicians; and increased use of telehealth and virtual communication.
Communication is at the core of the patient-physician relationship. Skilled clinician communication improves medication adherence, improves outcomes in chronic disease, decreases medical litigation, improves patient satisfaction scores, and even improves clinicians’ well-
being.1-17 As much as 60-90% of our communication is non-verbal.18,19 With some of our go-to non-verbal skills now rendered ineffective due to personal protective equipment (PPE), a heightened awareness of how we connect with our patients to build trust is essential. It also may serve as a catalyst to add new tools to our communication repertoire to enhance both our patient care and our encounters with colleagues and family members.
Don’t let your PPE distance you more from your patients. Instead, we encourage you to redouble your efforts to foster communication and trust using these techniques:
1. Ensure that you communicate clearly in a way the patient can understand.
• Do an audio check: “With the mask and face shield, it is often tough for me to communicate clearly. I want to check in with you. Can you understand me?”
• Ensure access to and utilize language interpreters.
• Share information in dialogue as opposed to monologue. A model for this is to offer a small chunk of information, then stop and check for understanding with an open-ended question before continuing an explanation. Excellent examples of this model can be found on the Academy of Communication in Healthcare COVID-19 resource page.
• Ask patients to repeat back what they’ve understood. “To make sure my explanations were clear and you were able to understand me through this mask, in your own words, what are the next steps?”
• For hearing impaired patients, find out if there is an ear that is better to speak to. For patients who rely on reading lips, can you communicate via video from a place where it is safe to talk without PPE? One innovative option for patients who read lips is a mask that has a clear front.20
2. Explicitly address emotion using words.
• Many of us have been socialized to avoid verbally stating our emotions or commenting on the emotions of others. Addressing emotions can take practice, but it can greatly deepen the connection you form with patients or colleagues.
• Name the emotion that the other person is expressing. “Thank you for sharing that this is frightening for you.” If a specific emotion is not stated, it is ok to hypothesize. “I sense that you are feeling really anxious right now. Is that right?”
• Explicitly name the emotion that you are hoping to convey. “That makes me sad to hear,” or “I am smiling with you under this mask.”
• Thank the patient for sharing his or her emotions, if appropriate. “I appreciate you sharing that with me,” or “I am glad to learn your feelings about this.”
• Validate and legitimize the patient’s feelings. “Anyone in your shoes may feel that way,” or “This is a very common reaction. You are not alone in feeling this way.”
3. Double down on the non-verbals that you can control (and still convey) in PPE.
• Sit at eye level with the patient.
• Pay attention to your voice intonation, volume, and rate. Address how your voice may come across. “I think if I speak slower (or louder) others can understand me better in this mask. Let me know if this is not necessary.”
• You still may be able to use eye expressions.
• Arm and hand movements can help convey empathy.
• Posture: Face towards patients with your whole body; lean forward in emotional moments.
• Touch: Avoid handshakes. Elbow bumps are an acceptable form of greeting. (You may consider asking for permission.) Use a brief, light touch on a shoulder or knee (bony prominences) as appropriate during emotional moments.
4. Seek the other person’s perspective. This allows the patient or colleague to feel understood.
• Ask about how their lives have been impacted. “How has this affected your daily life?” or “I am hearing you say you have not been able to work, and also that you are losing sleep.”
• Ask for the patient’s ideas about what is going on. “Some patients have specific ideas about what is causing their medical issues. What ideas or concerns do you have about what is causing your symptoms?”
• Explore patient (or colleague) expectations: “What were your expectations for today’s visit?” or “What outcome are you expecting?”
Gretchen Fuller, MD, is a pediatric emergency medicine fellow and emergency medicine physician at The University of Texas at Austin Dell Medical School.
Martha Howell, EdD, is a quality process improvement consultant for the Office of Patient Experience at Baylor Scott & White Medical Center in Temple, and vice president of Fiscal Affairs for the Texas Medical Association Alliance. Both are certified trainers and faculty in training at the Academy of Communication in Healthcare. The authors have no financial disclosures and would like to acknowledge the training tools provided by the Academy of Communication in Healthcare in this work.
References:
1. Biglu et al. Communication Skills of Physicians and Patients’ Satisfaction. Mater Sociomed. 2017;29(3):192-195.
2. Boissy A, Windover A, Bokar D, Karafa M, Neuendorf K, Frankel R, Merlino J, Rothberg M. Communication Skills Training for Physicians Improves Patient Satisfaction. J Gen Intern Med. 2016 Jul;31(7):755-61.
3. Dwamena et al. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database Syst Rev. 2012; Dec 12(12):CD003267.
4. Huntington, B., & Kuhn, N. (2003). Communication gaffes: A root cause of malpractice claims. Baylor University Medical Center Proceedings, 16, 157-161.
5. Institute for Communication in Healthcare. Impact of Communication in Healthcare. July 2011. https://healthcarecomm.org/about-us/impact-of-communication-in-healthcare/. Accessed 2/2020.
6. Krasner et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009; 302(12):1284-93.
7. Leaming Van-Zandt K, Zhu H, Banuelos R, Lopez M, Hsu D. Impact of a Relationship-Centered Communication Course on Patient/Caregiver-perceived Physician Communication Skills in a Pediatric Emergency Department. Pediatric Emergency Care online. 2019. PMID: 31851077 Accessed 2/19/2020.
8. Levinson W, Roter DL, Mullooly JP, et al. Physician–patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;277:553–559.
9. Luxford et al. Improving clinician-carer communication for safer hospital care: a study of the ‘TOP 5’ strategy in patients with dementia. Int J Qual Health Care. 2015; 27(3):175-82.
10. Manary M, Boulding W, Staelin R et al. The patient experience and health outcomes. N Engl J Med 2013;368:201–3.
11. McClelland et al. Compassion Practices, Nurse Well-Being, and Ambulatory Patient Experience Ratings. Medical Care. 2018; 56(1):4-10.
12. Mercer SW, Reynolds WJ. Empathy and quality of care. Br J Gen Pract. 2002;52:S9–12.
13. Nafradi et al. The doctor-patient relationship and patient resilience in chronic pain: A qualitative approach to patients’ perspectives. Chronic Illness. 2017; 14(4):256-270.
14. Pollak K et al. Effect of teaching motivational interviewing via communication coaching on clinician and patient satisfaction in primary care and pediatric obesity-focused offices. Patient Educ Couns. 2016; 99(2): 300-3.
15. Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995;152:1423–33.
16. White et al. Health communication, self-care, and treatment satisfaction among low-income diabetes patients in a public health setting. Patient Educ Couns. 2015; 98(2):144-9.
17. Young et al. The influence of patient and provider communication on diabetes care delivery. J Ambul Care Manage. 2016; 39(3): 253-63.
18. Mehrabian, Albert (1971). Silent Messages. Belmont, CA: Wadsworth. ISBN 0-534-00910-7.
19. Birdwhistell, Ray (1970). Kinesics and Context: Essays on Body Motion Communication. Trustees of The University of Pennsylvania. ISBN 0-8122-7605-1.
20. Chodosh J. et al. Face masks can be devastating for people with hearing loss. BMJ 2020; 370 doi: https://doi.org/10.1136/bmj.m2683.