Reflection can be an excellent communication tool to use when a patient is angry about a diagnosis.

A positive doctor-patient relationship is the key to medical care.  Substantial evidence indicates that a relationship of trust and respect promotes better adherence to treatment recommendations, better physical and emotional outcomes, the disclosure of patients' hidden concerns, and furthermore, that the absence of a good relationship is an impairment to high quality medical care.

1. Think about your own ways of connecting with friends and others.   Which of these skills could you apply to building relationships with patients?
2. Which of these skills do you consider most important for building relationships with patients?
3. What attitudes do you have about yourself that might get in the way of building relationships with patients?
4. How do people see you as a person? What are your hopes for how patients will think of you?

1. Relationship building is crucial at the start of the contact but must continue throughout and be integrated with data gathering and patient education
2. Relationship building reflects a combination of non-verbal behavior (attentiveness, responsiveness and warmth) and explicit comments and questions to show a caring interest in the person, not just the medical condition
3. Relationship building interventions work best when they reflect your genuine thoughts and feelings
4. Relationship building interventions should be moderated by your awareness of your own biases and emotional reactions in responding to patients’ personal / emotional issues

At the conclusion of this module, you will be able to:

• State at least five reasons why relationship building is key to medical care
• State three key principles of relationship building
• Demonstrate five basic relationship building skills

Patients expect their doctors to be knowledgeable and technically competent. But they also want their doctors to be reassuring, supportive, and emotionally available.

Clinicians with effective relationship skills will have more satisfied patients who will better adhere to treatment recommendations.  Furthermore, the clinician with effective relationship skills will cope with emotionally troubling situations better and will, in general, find the clinical practice of medicine more enjoyable. Such a clinician will be able to give more emotionally to patients and will, in turn, get more satisfying responses from them. There is a substantial body of evidence about the importance of clinician patient relationships in outcomes of care.

For example, in a study of over 7000 patients, clinicians' comprehensive ("whole person") knowledge of patients and patients' trust in their clinician were the variables most strongly associated with adherence, and trust was the variable most strongly associated with patients' satisfaction with their clinician.(1)  You can achieve a “whole person” knowledge of patients by building supportive, caring relationships.  In a meta-analysis of studies on the relationships of clinician communication and outcomes of care, clinicians’ providing positive affect, empathy and support emerged as an important factor in promoting positive patient outcomes.  This study found that when clinicians ask about patients' understanding, concerns, expectations, and impact of illness on function, it leads to decreased anxiety and promotes symptom resolution. Clinicians asking about patients’ feelings leads to decreased patient distress, and when clinicians provide support and empathy, there is both decreased patient distress and better symptom resolution.  In studies of medical outcomes, when patients feel that they have been able to express themselves fully (feelings, opinions, information), they later have improved health and functional status, and better BP control. Moreover, when patients feel there has been a full discussion of their problems, they experience better symptom resolution.(2)

• Attentiveness and Warmth
  Attentiveness to the patient as a whole person and not just attentiveness to diagnosis and management of the diseased part of the person, is the prerequisite of all relationship building. Showing attentiveness and warmth is done through a range of non-verbal and verbal behaviors.
• Communicating Empathy
  Empathy is a term indicating one's appreciation, understanding, and acceptance of someone else's emotional situation.
• Respect
  Your respect for patients and their problems is conveyed not only by non-verbal signals, attentive listening, eye contact and genuine concern but also by explicit statements of respect for their views and praise for their efforts.
• Support
  You should make explicit efforts to let the patient know that you are present, personally, for the patient and that you wish to help.
• Promote Partnership
  Patients are more satisfied and are more likely to adhere to treatment recommendations when they feel a sense of partnership with their clinicians.
  

Once you learn these skills, you can integrate them into your natural style of relating.  This integration provides the foundation for you to master higher-order skills for continued relationship-building, for helping patients cope better with emotional distress, and for properly managing complex and complicated situations.  These include working with dying patients or those with alcohol problems or those with the most severe illnesses such as major trauma or leukemia, communicating bad news, and helping angry patients manage- to name just a few such situations.

Not only does the demonstration of warm attentiveness in itself create a positive impact but also all the other components of relationship building depend on attentiveness. If you do not constantly pay attention to the person as well as to diagnosis and management you will fail to spot the appropriate moments for demonstrating empathy, respect, support and partnership.

Attentiveness is demonstrated by both non-verbal and verbal behaviors.

Non-verbal behavior and ‘para-verbal’ behavior (tone and pacing of speech) are the most powerful determinants of the emotional impact of any interaction. Warmth and attentiveness are demonstrated through eye contact, voice tone, nods and uh-huh’s, responsive facial expression and forward posture. Attentive silence can have a powerful positive impact and is considered in more detail in this module's section on empathy.  A more detailed overview of non-verbal behavior appears in module 14.

You should strive for consistency between your verbal and nonverbal behavior. For example, if there is a disjunction between your verbal statements of concern and your nonverbal behavior, which may reflect your disapproval of a patient's behavior, your nonverbal message will usually prevail for the patient. (3)

An emerging body of research supports these contentions. Doctors who establish appropriate eye contact are more likely to detect emotional distress in their patients. Doctors who perform better on tests of nonverbal sensitivity have patients who are more satisfied. Doctors who lean forward and have a forward head lean and open body posture also have more satisfied patients.(4)

In addition, patients’ nonverbal behaviors are keys to their emotional lives. Most patients express their emotional state through facial expression, body posture, movement, tone of voice, inflection, and physical manifestations of autonomic nervous system reactivity (sweaty palms, flushed face, etc.). Clinicians interested in understanding their patients' emotional states will look for these signs and consider their importance at every stage of the communication process.

In general, you should establish and keep comfortable eye contact with the patient throughout the interview. This is essential for active and effective listening and also to be able to observe emotional cues as they arise. As with all rules, there are exceptions: angry, suspicious, and/or paranoid patients can perceive steady eye contact as provocative.

Thoughtful attention to the use of space also facilitates rapport. Vertical space between doctor and patient should be minimized (e.g., not standing while the patient sits) and horizontal space should be carefully planned (e.g., not too close or too far).

The power of the various relationship building skills you will master, and the intimacy and social power differentials that accompany caring for people who are ill and vulnerable require you to be especially mindful of appropriate boundaries in your doctor – patient relationships.  Doctors’ skills repertoire needs to include respectful ways of reinforcing those boundaries if and when the need arises. (module 41)

Verbal demonstration of attentiveness is largely through ‘active listening’ (described in more detail in module 8, "Gather Information").  Active listening includes ‘continuers’ (encouraging comments) such as ‘please tell me more’ and reflection (repetition) of key phrases used by the patient ("I see ...the pain was severe").  Expression of your own emotional response to the patient’s experience (e.g., "my goodness .. how awful") can also be a powerful way to indicate attentiveness.  However, your expressions of emotion must be titrated so that they do not burden or distract the patient.

The communication of empathy is one of the most helpful, meaningful, and comforting interventions one person can have with someone else. A parent soothes an upset child by letting the child know that the distress is understood, appreciated, and accepted. Friends can do the same. Similarly, a clinician can build rapport and respond to patients' emotions best by the communication of empathy.(5)

Sometimes clinicians are reluctant to encourage the patient to express feelings more deeply by expressing empathy. They may feel that this will open a "Pandora's box" of emotions or that empathic comments will "push" patients to express feelings that they might otherwise wish to keep private. Research suggests though, that it is helpful and supportive to allow patients some opportunities for the ventilation of feelings that are near the "surface" of awareness. Such interventions help develop rapport and trust. And contrary to the worry that expressions of empathy can unnecessarily prolong the interview, there is evidence that a little empathy goes a long way,(6) and can make your interactions with patients more efficient.

The communication of an empathic understanding of a patient’s predicament is clearly the most important relationship-building skill the clinician can possess. There are many different ways to communicate empathy effectively. The challenge of learning empathic skills lies in the ability to master basic interventions and to integrate these into a natural interpersonal style that feels genuine to you and, as such, is likely to be perceived as genuine by the patient.

Nonverbal behaviors can sometimes communicate empathy more effectively than can concrete statements. A sympathetic look, attentive silence, and a hand on the shoulder can all accomplish a great deal towards letting the patient know you are emotionally in tune with the patient's distress. Genuine interest in the patient’s life, feelings, worries, expectations and hopes communicate empathy.

Most students and clinicians already possess natural empathic abilities, but the challenges of medical practice often require the development of additional skills. Clinicians need to ask patients about very personal issues, and patients will often tell their clinicians things they tell no one else, such as sexual problems or stories of physical and sexual abuse. It takes learning specific skills, practice and experience to become comfortable eliciting and listening to patients’ most personal concerns.

A word on attentive silence: It is a valuable skill: it wordlessly communicates concern, interest and respect. It counters the impressions many patients hold that “doctors don’t listen to their patients.” It gives patients an opening to discuss their most troubling issues. When a patient interrupts a narrative and falls silent, or expresses a strong emotion, it is wise to remain silent. If the silence lasts more than about 5 seconds, you can gently say, “what are you feeling?” or “are you able to talk about it?” Most beginning learners have great difficulty with attentive silence, often feeling the need to change the subject or reassure the patient. But attentive silence has many rewards for patient and clinician

Click on the picture-button on the left to experience the nonverbal skill of attentive silence.

This chapter describes two operational components of empathic communication, “reflection” and “legitimation,” that can be used to facilitate your responses to patients' emotional distress. Reflection refers to your description of the emotion experienced by the patient and legitimation refers to the clinician’s confirmation that the emotion is understood and accepted.

If you notice that a patient begins to look sad when discussing the illness of a parent, examples of ways you can "reflect" this feeling include the following:

This type of reflective comment usually helps you communicate empathic concern for the patient's emotional situation. In practical terms, such comments usually give patients permission to talk more about their feelings. Patients often then go on to reveal important information that helps you better understand their illnesses.

Click on the picture-button on the left to see an example of reflection.

The specific words you use are much less important than the fact that you have interrupted the factual exchange of information to notice and respond to the patient's emotional state. This is a critically important event in the building of a relationship with a patient and demonstrates to the patient that you are concerned about the patient as a person and his or her emotional experiences.

When you make reflective comments about sadness, patients will often begin to cry, which can make you uncomfortable, and want to either “fix” the problem, reassure the patient, or change the topic. However, a patient’s crying is a good sign – it indicates that the patient trusts you. Also, crying in the presence of a caring clinician is often therapeutic for patients. It is best to respond to patients’ tears with attentive silence, and offering a tissue.

After you make reflective comments, patients may indicate that they do not wish to discuss their emotional reactions, and you should of course respect these desires. It is important however, that you do not confuse your own discomfort or desire to avoid emotional issues with the inference that it is the patient who wishes to avoid these topics. Sometimes, patients are reluctant to talk about difficult emotional issues because of guilt or shame,(8) or their worry that you will not be open to listening, or might be judgmental. Often, a comment such as, “it’s pretty hard to talk about this…” followed by attentive silence, will reassure the patient and enable them to disclose their feelings.

On the other hand, if you do not acknowledge a patient's manifest feelings, the patient will feel less understood and unconfirmed. Such feelings undermine doctor-patient rapport and actually interfere with collection of data.

One of the cardinal rules of good interviewing is the following:

Respond to a patient's feeling as soon as it appears

Remember that reflective comments can be utilized several times as a patient discusses and experiences feelings. One reflective comment may be insufficient. In fact, as a patient expresses emotional reactions, the specific feeling expressed may change in quality and degree. For example, a patient who seems sad at first may eventually express anger or frustration or vice versa. If the clinician listens carefully, the initial feeling can be acknowledged and subsequent ones reflected as they emerge.

Such attention to patients' feelings seldom requires excessive time, and may contribute to efficient interviews by removing emotional obstacles to full disclosure of symptoms and circumstances. Clinicians trained in responding to patients' feelings can have profound effects in relieving emotional distress without lengthening the medical visits.(9)  If the emotional issues become too complex to address in the interview time available, you can acknowledge the significance of the feelings and make arrangements to deal with the emotional issues at a later, but acceptable date. Alternately, a suitable other approach, e.g., a psychiatric, psychological, or social work referral, could be arranged.

Examples of validating comments would be:

Click on the picture-button on the left to see an example of legitimation.

With respect to validating the feelings of someone who is angry, making a legitimizing statement does not mean that you agree with the reasons for the anger. The point is that you are trying to understand this anger from the patient's point of view.

Once you have understood the anger, you can communicate this understanding to the patient. This is sometimes difficult to do if you disagree with or feel irritated or threatened by an angry patient.  Nevertheless, reflective and validating comments can play the same helpful role with angry patients as they do with sad or anxious patients.

For example, if the patient is angry because he or she has been waiting too long, you might say:

These principles are highlighted again in module 13.

For the purposes of this text, an intervention communicating respect refers to a specific endorsement for a specific patient behavior. Statements of respect which validate patient behaviors will, in general, tend to reinforce the behavior, i.e. make it more likely to happen again. Frequent demonstrations of respect will foster a positive relationship and promote the patients' capacity for coping.

Click on the picture-button on the left to see an example of respect.

Clinicians can usually find something to praise in all their patients. Most everyone does something well. This holds true even for patients with troubling or difficult behaviors (cf. module 13). Doctors can help their patients by focusing on one or more of their patient's successful coping skills. This will improve patient satisfaction and adherence. Examples of respectful statements would be:

Like all the other interventions discussed above, statements of respect must be honest, or they will be more destructive than helpful. When these sentiments reflect true feelings of the clinician, however, they are powerful facilitators of improved communication and rapport between doctors and patients.

Comment for medical students and residents:
Depending on your level of training, you may be aware of a “hidden curriculum”- what you learn about attitudes and behaviors toward patients from other residents and attending clinicians. Some residents and attendings may call patients names such as “gomers” or “crocks.” They may be abrupt with patients or avoid difficult conversations. They may not demonstrate the kind of empathy and concern that you would want to have in your relationships with patients, or that you would want for your loved ones if they were ill. Some residents and attendings will deride your interest in patients as irrelevant, perhaps describing it as “warm and fuzzy.” If you are a trainee, it is easy to fall into the rhythm of a prevalent culture, and to develop cynicism and doubt. If you practice the relationship skills in this module, and realize the value of connecting more deeply with patients; if you experience the positive effects that your skills have on your understanding of patients’ illnesses and their well-being, you are more able to withstand the pressures of the “hidden curriculum.”

This of course must be an honest statement, or it will not be effective. Statements like the following indicate personal support:

Click on the picture-button on the left to see an example of personal support.

The assurance of direct personal support is partidcularly important when situations are changing rapidly or in those situations where there is considerable uncertainty about diagnosis or treatment, or where anxiety or tension or conflict is paramount.  Your statement of personal involvelment means a lot, and leads to improved rapport and solidification of the doctor-patient relationship.

Truly working together as partners cannot occur unless clinician and patient agree on an understanding of the task in hand. The first task is the process of the interview itself. It may sometimes therefore be helpful for the clinician to offer brief explanations in advance of certain components of the interview such as the inquiry into personal and social factors. An example might be, "It would be helpful to know a bit about your personal circumstances because sometimes this has a bearing on how best to sort out your problem." (module 5)

Increasing the participation of the patient in his or her own treatment improves the patient’s coping skills and improves the likelihood of good outcome from illness processes.  Clinicians' work is much easier when patients sense a clear joining together to find the best solutions, especially for thorny and difficult problems. 

Click on the picture-button on the left to see statements of respect and partnership.

Physicans can promote this type of partnership, by making statements like the following:

1. Demonstrates non-verbal warmth and attentiveness
   - Appropriate eye contact (direct eye contact most of the time)
   - Appropriate tone of voice (demonstrates concern and interest)
   - Appropriate pace of interview (not too fast or too slow)
   - Appropriate posture (generally forward lean of head and body towards patient)
   - attentive silence
2. Demonstrates verbal warmth and attentiveness
   - greeting shows genuine interest in patient as a person
   - explain the situation
   - summarize patient’s main concerns
   - state that patient’s concerns are your primary focus
   - choose words that indicate concern for the patient and interest in the patient
   - respond to emotion right away
   - invite participation
   - encourage participation
3. Demonstrates specific verbal relationship responses
   - reflection (notice and name emotion)
   - legitimation (validation- accept the emotion)
   - support (direct personal offer of support)
   - partnership (direct offer to join together)
   - respect (specific endorsement for specific behavior or trait)
   - interrupt silence (or factual exchange) to respond to emotion
   

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6. Fogarty LA, Curbow BA, Wingard JR, McDonnell K, Somerfield MR. Can 40 seconds of compassion reduce patient anxiety? J Clin Oncol. 1999;17:371-9.
7. Carkhuff RR: Helping and Human Relations, vols 1 and 2. New York, Holt, Rinehart, Winston, Inc., 1969, pp. 1-298, 1-343.
8. Lazare A. Shame and humiliation in the medical encounter. Arch Intern Med. 1987;147:1653-8.
9. Roter D, Hall J, Kern D, et.al. Improving clinicians' interviewing skills and reducing patients' emotional distress. A randomized clinical trial. Arch Int Med. 1995;155:1877-84.
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11. Is there a core neural network in empathy? An fMRI based quantitative meta-analysis. Neurosci Biobehav Rev. 2011;35:903–911.
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06: Build the Relationship - by Julian Bird MD and Steven Cole MD

What are some guidelines you should follow for patient teaching to be successful?

Which model analyzes what people believe to be true about themselves?

Which of the following would be an appropriate method of conveying empathy when obtaining a patient's medical history?

What is a major disadvantage to physician centered communication?