Patient Communication Part 2: Communication Skills

on March 1, 2017 by Chris Kresser

Good communication is the foundation of successful healthcare. It has been shown to improve clinician–patient rapport, patient satisfaction, clinician satisfaction, and more. Despite this, most clinicians have little or no required communication training. Thankfully, communication experts Oren J. Sofer and Evan A. Wong have created a communication skills training program, coming out summer 2017, that I cannot recommend highly enough. It combines mindfulness and Nonviolent Communication—and is designed specifically for healthcare practitioners. Read on to learn why communication skills are so important and how this new program can help you master them.

This article is the second of a two-part series. To read Part 1, click here.

Communication with patients and among members of your team is one of the most important factors that determine your clinic’s success. Many patients are dissatisfied with the poor communication they experienced in conventional medicine: rushed appointments, brash clinicians that did not include them in decision-making, incomplete explanations, and a lack of emotional support. Studies have consistently shown that patients want better communication with their clinicians, (1) and functional medicine aims to offer it. We want to provide “high-touch care,” in which the patient is fully heard and supported and plays an active role on the healthcare team.

So, how do we realize our goal of high-touch care without overextending ourselves? It requires both strategic clinic organization, as discussed in Part 1, and solid communication skills.

I consulted Oren J. Sofer, a mindfulness and communication teacher, and Evan A. Wong, a palliative care chaplain at University of California, San Francisco Medical Center, for more insight into the fundamental role of communication in healthcare.

Good communication improves clinician–patient rapport, patient satisfaction, and clinician satisfaction

“The patient will never care how much you know, until they know how much you care.”
—Terry Canale, AAOS Vice-Presidential Address, 2000

Patients suffering from chronic illness may be desperate, scared, and in severe pain; they may be exhausted and mistrustful of medical professionals. It goes a long way to have a warm, caring relationship in which their input is welcome and their questions are answered.

Clinician–patient rapport

Building a trusting relationship through good communication allows clinician and patient to understand each other’s feelings, needs, and ideas. This helps the clinician obtain essential information, collaborate with the patient, ease suffering, facilitate comprehension of medical information, (2) increase treatment adherence, (3) and even improve objective and subjective measures of health outcomes. (4)

In Evan’s experience, unacknowledged emotions can be a barrier to the clinician getting important information. A patient may have a hard time processing information effectively when he or she is scared or overwhelmed. A skilled clinician can empathetically address this emotional layer first. Once emotions are calmed, the patient can think more clearly, help problem-solve, and—if they feel safe—share information more openly. This gives the clinician more real data to work with. As Evan explained, “With good communication, there are two people on the case instead of one.

Clinicians can also use their relationship with patients to ease suffering. A recent study reported that patients view clinicians as a primary source of psychological support. (5) An empathic clinician can make a patient feel understood, less alienated, and less stressed. Good communication can also offer patients a sense of agency or control. In her palliative care work, Evan sees patients with varying levels of pain. When patients’ needs for understanding and empathy aren’t met, if they don’t feel heard, this can increase their level of distress and exacerbate their pain. On the other hand, when patients know that their clinician understands them, they can relax, participate in conversations about their care, and focus on getting well. Indeed, research shows that a patient’s sense of control is associated with better pain tolerance, recovery from illness, ability to function, and mental health. (2)

A strong clinician–patient rapport is particularly important when delivering difficult news. (6) A skilled clinician can own his or her authority and still be clear, gentle, and decisive. Oren emphasized how reassuring and helpful this can be to a patient who is feeling overwhelmed or scattered. A patient who feels supported is better able to comprehend medical information and feel confident about the next steps.

Good clinician–patient rapport also increases the likelihood that your treatments will be effective. A 2010 meta-analysis found that clinicians trained in communication skills had improved patient adherence to recommended treatments, and that good communication was highly correlated with greater patient adherence in general. (3) Furthermore, clinical trials on diverse, chronically ill patients have consistently demonstrated that good clinician–patient communication is associated with better physiological, functional, and subjective health outcomes. (4)

Patient satisfaction

Patients consider “bedside manner” a major indicator of their clinicians’ overall competence. (7) In fact, most patient complaints are related to communication, not technical competence. (8, 9) Studies have consistently shown that the root cause of malpractice claims is often poor communication, which leads to a breakdown in the clinician–patient relationship. (2, 10) A research review summarized the phenomenon:

“Simply put, patients do not sue doctors they like and trust. This observation tends to hold true even when patients have experienced considerable injury as a result of a ‘medical mistake’ or misjudgment.” (10)

Furthermore, as Oren highlighted, patients will be more satisfied if the clinician is attuned to their needs and preferences for how they want to be helped. Most clinicians unconsciously use the same style of care with all patients. They are unaware of the spectrum of styles patients may prefer, which range from a more directive approach, in which all power is entrusted to the clinician, to a more passive style in which the patient holds the clinician as a consultant. Most patients prefer a collaborative approach between these two extremes. A skilled clinician can discern what is needed when, and adjust accordingly.

Clinician satisfaction

Interacting all day with those suffering from illness can be draining. Burnout is a serious risk for clinicians, and one study found burnout to be associated with insufficient communication skills training and poor relationships with patients and staff. (11) Not only is good communication helpful for patients, but it increases clinicians’ satisfaction. Better communication protects against burnout by helping clinicians build meaningful relationships, reduce work-related stress, and guide patients to better health outcomes. (2)

Good communication improves clinician–patient rapport, patient satisfaction, and clinician satisfaction.

As Oren noted, communication training can help you set appropriate boundaries, care fully for patients’ well-being without overextending yourself, and learn to receive genuine gratitude from patients. Skilled communication with coworkers can allow you to collaborate and handle differences with ease, which further conserves precious energy.

Nonviolent Communication (NVC) training is a helpful starting place

As you can see, communication is a crucial part of healthcare. It is hard to believe that most clinicians receive little or no training in this area. Seminars offered by institutions are typically brief and surface level, if they are offered at all. For robust training in communication skills, you have to seek it out yourself. It is a worthy investment; unsurprisingly, studies have shown that communication skills training significantly improves clinician–patient communication. (12, 13)

In my experience, two of the best ways to improve communication are to practice mindfulness and Nonviolent Communication (NVC). I have a few specific recommendations that can help you do that.

The system of Nonviolent Communication was developed by Marshall Rosenberg and is described in his classic book Nonviolent Communication. I studied NVC for years and even taught NVC workshops and worked with private clients before switching to a career in medicine.

Nonviolent Communication is founded upon the following premises:

  • Human beings are compassionate by nature
  • We all share the same basic needs
  • Our actions are strategies to meet one or more of those needs
  • Most conflicts are not about differences in needs, but in the strategies we employ to meet those needs
  • Violent strategies, whether verbal or physical, are learned behaviors taught by culture
  • When we can identify the feelings and needs present in a situation and truly empathize with another person’s needs, we are more likely to find a solution that works for both parties.

Marshall Rosenberg passed away recently, but the Center for Nonviolent Communication training is still going strong in 65 countries, with trainers and workshops in most major cities in the United States. The center also offers retreats, books, videos, workbooks, and more.

Mindfulness is the missing piece to NVC training

While I agree with the underlying philosophy of NVC, I found that it sometimes backfires in practice. If you apply the techniques of NVC without being present and connecting to a genuine motivation of collaboration and good will, it can seem inauthentic. It can lead to distrust and fear of being manipulated.

So, how can we learn to stay present and get in touch with the feelings and needs that are going on under the surface, especially in difficult situations? The key is a practice that cultivates mindful awareness. To learn more about the important role mindfulness plays in communication, one helpful book is The Art of Communicating, by Buddhist meditation teacher Thích Nhất Hạnh.

Combining the basic tenants of NVC—where we drop below thoughts, strategies, and judgments to connect with feelings and needs—with mindfulness practice is a powerful approach to communication.

While reading books on communication will provide a good foundation, I highly recommend doing some in-person or video training, either in groups or one on one. It’s one thing to understand principles of mindful communication intellectually while calmly reading a book, but it’s entirely another to embody them in the heat of conflict. When you role-play tense situations, you will likely find the experience very different.

Enter communication experts Oren J. Sofer and Evan A. Wong. Their upcoming program teaches communication skills using the key ingredients of mindfulness and NVC—all in a course specifically for healthcare practitioners.

Their course, “Building the Foundation of an Effective Healthcare Practice with Mindful Communication,” will launch summer 2017. The course is designed to give practitioners tools to enhance their clarity and creativity, increase resilience, reduce burnout, and improve patient satisfaction. By sharpening clinical communication skills and refining intake abilities, you’ll be able to build collaborative relationships with staff and patients and achieve the best outcomes for patients.

Oren and Evan’s course gets at the heart of healthcare. When we look at medicine, the foundation is an exchange of information between patient and clinician—it’s all built on communication. Good communication, in turn, is built on meaningful relationships. In Oren’s words, “A lot of the information clinicians get is based on asking the right questions, listening properly, and drawing a patient out. It all depends on the level of trust and safety established with the patient.”

So, then, how do we build meaningful relationships? It begins with our presence and good-hearted intentions. Oren and Evan’s course works on these skills from the ground up:

  • Presence: bringing all of yourself to each interaction
  • Embodying your intentions
  • Relationship building
  • Communication

The first step toward good communication is presence. We can’t communicate well with someone if we’re not actually here in this moment. Are we stressed, overworked, and rushed? Or can we have a sense of spaciousness and patience and give the patient our undivided attention? Are we checking off boxes on an intake form? Or are we genuinely interested and available, actually seeing and listening to the person in front of us?

The next step is knowing where we’re coming from. Oren poses the question: “What are our intentions as clinicians, and are we able to access these intentions in our day-to-day work?” Some powerful intentions for clinicians include: to understand, to care deeply, to be patient and curious, or to prioritize the patient’s needs in the time allotted. Mindfulness helps us identify these intentions and stay connected to them during our work.

Mindfulness practices build presence, which allows us to stay true to our intentions—even during conflict. Our nervous systems have been conditioned to activate in response to conflict. The stress response is natural but often disproportionate to the situation and ultimately unhelpful. Mindfulness teaches us to be aware of and work with activation in our nervous system, helping us to step back and make conscious choices about how to react—or not react—in tense situations.

A unique insight into clinician–patient communication

Oren and Evan are uniquely suited to teach this course. Both have extensive training in mindfulness and NVC, but they come from different backgrounds. Oren teaches retreats and workshops around the country in mindfulness meditation and NVC. He recently contributed to 10% Happier, a meditation app created by ABC News anchor Dan Harris, who included Oren in his list of “the most respected meditation teachers on the planet.” Evan, on the other hand, works in a large research hospital as a palliative care chaplain. In this setting, Evan sees patients communicate with a variety of healthcare practitioners—including doctors, nurse practitioners, nurses, and social workers—and witnesses where communication tends to break down. Evan’s role is to address emotional, psychological, and spiritual needs of patients in medical situations. This is a key piece of healthcare that most clinicians aren’t trained to do and often don’t consider part of their responsibility. In functional medicine, we do tend to be more tuned in to working with both the body and the mind, but most of us would still benefit from thorough training.

Stay tuned for more information on the nuts and bolts of the course and how to sign up!

Communication skills training is probably one of the most effective investments you can make in your continuing education as a clinician. The powerful tools of clinic organization (discussed in Part 1) and communication skills can help you offer patients a level of care they have never experienced in the conventional model—all while leaving you less overwhelmed and more satisfied with your work.

Now I’d like to hear from you. Did you know how big an impact good communication can have on patient experience? What resources have helped you learn to communicate better with patients? Let us know in the comments below.

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  1. Back when I was a student in the chiropractic program, a group of students started an NVC group. I sat in on a few meetings which sparked my interest. Even the most basic exercises in making an observation, imagining how the other feels, and trying to uncover his/her need(s) were powerful tools for me! I started applying NVC not only with my patients, but with my family and partner to deepen my relationships. I have definitely found it effective to practice in person.

    Another tool I have used involves Heart Rate Variability (HRV) through the emWave device and app. I have found that HRV has enabled me become less reactive by taking a bit of extra time to mindfully respond.

  2. Such an important subject for practitioners. I have never had formal training so have learnt through years of client time. I look forward to hearing more about the course.

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