Therapeutic Relationship and Communication with Patients

by Mark Hughes, MD, MA

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    00:00 In this lecture, we're going to talk about healthcare team relationships and how they bear on ethical practice.

    00:08 At the heart of clinical medicine is the therapeutic relationship, the relationship between the clinician and the patient to try to achieve the patient's well-being; to keep them healthy, if they're healthy; if they're ill, to get them feeling healthy.

    00:22 If it's pediatrics and we're dealing with a child as the patient, then it's also involving the parents, so a tripartite therapeutic relationship.

    00:32 At the core, at the heart of all those relationships is trust.

    00:36 So the mutual respect that each party shows to each other is foundational to establishing trust and making sure that the relationship can work over time.

    00:46 And as I said, the reason we go into this therapeutic relationship is to promote the patient's rights as well as their best interest.

    00:55 So we have both the legal duty to do that as well as an ethical duty.

    01:02 The standards and expectations are sort of conferred by the law and by our professional standards that we're going to be confident, that we get certification for the work we do as clinicians and that we adhere to appropriate behavior and judgment, which we talked about in the professionalism lecture.

    01:22 And always in this effort in the therapeutic relationship, we're trying to aim for patient and family centered care, putting them at the center of the relationship.

    01:33 It's also important to note that we as clinicians are also in relationship.

    01:38 So, we're getting something out of this relationship as well.

    01:42 It is more one side in terms of really being focused on the patient, but the clinician, you know, can feel very strong bond with their patient.

    01:51 And acknowledging that the relationship is also important and maintaining it, restoring it if it's, you know, get severed, making sure that it works over time is going to really aid in the therapy and the therapeutic relationship for everybody.

    02:12 Alright, so what are the qualities that you need to have as a clinician to establish good relationship with patients? First and foremost, you know, is you have to be competent.

    02:24 You have to have the knowledge, the technical skills, the ability to problem solve.

    02:28 You know, patient is coming in with a particular problem, you've got to be able to figure out what's causing it and how you're going to take care of it.

    02:38 As a clinician, you also need to bring empathy and compassion to the relationship.

    02:43 So, feeling what the patient is going through, the suffering that they are experiencing and being moved towards doing something about that, trying to ease their suffering.

    02:55 As I mentioned, you know, to establish trust you need to be respectful.

    03:00 So, it's demonstrating both in your behavior, in your language, in how you interact with not only the patient but their family that you show respect.

    03:14 It also requires, you know, to maintain this relationship over time that you are diligent; that you are committed to keeping the relationship going good; you're making sure that you're attending to the details so you're not letting things, you know, slide by the wayside; you're being responsive when the patient, you know, has questions or concerns; you're trying to figuring them out for them.

    03:39 There's a certain amount of resilience that's also required to maintain a good relationship with patients.

    03:45 So, we certainly seen that their clinician well-being is important in this.

    03:52 Not just achieving the patient's well-being, but making sure you're taking care of yourself so that you can be there for your patient.

    04:00 And lastly, you need to have good interpersonal skills.

    04:03 So, how do you establish rapport with the patient? How do you build up rapport over time? Can a patient feel comfortable, you know, in coming to you, talking to you about their concerns especially about, you know, maybe difficult topics? It requires good communication skills, so being a good listener.

    04:21 And also in how you speak, that you are understandable, that you are speaking at a language that the patient can really figure out what's being said, it's not just the medical jargon but really trying to make it so the patient is getting a lot out of the relationship.

    04:41 It also means that communication is nonverbal and some would say that, you know, 90% of communication is non-verbal.

    04:47 So, the body language that we demonstrate to a patient is a means of communicating with them and building that rapport.

    04:54 So, it's also important to just check yourself and make sure that you're doing things that are showing the patient that you are interested, that you are listening, you are attentive to their needs.

    05:06 So, one way to do that is establishing eye contact with the patient.

    05:09 Now, there are some cultural norms about, you know, how much eye contact you should have with the patient but trying to be at the same eye level, checking in with them, you know, through eye contact.

    05:20 Maybe you mix it up a little bit, you know, and always stare at them that might get a little overwhelming for a patient.

    05:27 Generally having a relaxed posture.

    05:28 So, some inviting posture that says, you know, you want to hear from the patient.

    05:36 You might learn, you know, communication skills where you're trying to match body language.

    05:41 So that's another way of building rapport.

    05:44 If you see the patient is in a particular posture, if you assume the same posture, you know, or close to it that matching is a way of showing that you're trying to, you know, connect with the patient.

    05:58 And even it's at a subconscious level.

    06:02 Your facial alertness and animation.

    06:04 So, varying your facial expressions in relation to what the patient is saying or how you are intonating, you know, what you're saying.

    06:12 All of that sort of shows that you're invested in the relationship.

    06:19 Any kind of encouraging body posture.

    06:21 So the head nods, the head tilts, leaning forward, all of these might facilitate this nonverbal communication in connecting with the patient.

    06:33 There have been studies that showed that, you know, physicians often interrupt patients pretty early in a clinical encounter.

    06:40 So, you know, trying to minimize that and just use brief vocalizations that encourage the patient to do more talking.

    06:48 So the uh hums or the ah has are ways to make sure that you're getting them to do the talking that not just you talking.

    06:57 As I mentioned, the intonation of your voice or moderating your voice volume, again trying to match, you know, the patient's voice volume is a good way to build rapport.

    07:12 And then as we're going to talk about later in the lecture, you know, there are also aspects of physical contact that can be therapeutic.

    07:20 So, a hand on the shoulder for a patient that is, you know, having an emotional reaction to something they've learned, you know, perhaps some bad news, a new diagnosis or something.

    07:33 That non-threatening physical contact is a way of building rapport.

    07:40 It's also important to point out that, you know, you have to be aware of underinvolvement.

    07:44 So, you know, we talked about a doctor's bedside manner and how far that can go to building trust and making patients feel comfortable in the therapeutic relationship.

    07:58 So, you know, if you're cold or distant or more formal, you know, don't seem easy going to get into a conversation or build a relationship with the patient, they might be a bit dismayed about that.

    08:13 Being dismissive of a patient.

    08:15 So disregarding what they are saying and just going with your own agenda.

    08:20 Being distracted and that becomes increasingly, you know, harder as we have documentation in electronic medical records, you know, we see clinicians sort of focused on the screen rather than on the patient.

    08:34 So, that inattention to the patient and what they're experiencing not being in the moment with them, being distracted by other things or, you know, looking at a mobile phone or checking a page that you've gotten, you know, about another patient.

    08:50 All of those can you show sort of underinvolved and not really invested in this patient that's in front of you.

    08:57 So it's also important to make sure you're paying attention to unwelcoming body language.

    09:03 So the crossing the arms or crossing your legs as a sign that you're sort of being defensive, that you're not being receptive and open to what the patient is saying, pointing an index finger at the patient.

    09:15 It might be fine to point a finger at a diagram that you're showing a patient, but actually pointing a finger at them may put them on the defensive.

    09:23 And maybe avoiding eye contact or staring.

    09:26 You know, we talked about that before where, you know, if you're not really establishing good eye contact then building rapport that way or staring them down or just, you know, looking away and not even paying attention then they may feel disconnected.

    09:40 Showing signs of nervousness on your part.

    09:42 So, fidgeting, wringing your hands, actually sweating, you know the patient is going to start to think well what's going on with this clinician, why are they so nervous about talking to me.

    09:53 Any kind of frustrated vocalization.

    09:56 So the "th" sound when a patient says something, they may feel like "Why is the clinician doing that?" You know. "Are they dismissive of what I'm saying?"

    About the Lecture

    The lecture Therapeutic Relationship and Communication with Patients by Mark Hughes, MD, MA is from the course Communication with Patients and within the Health Care Team.

    Included Quiz Questions

    1. Patients and families
    2. Families
    3. Other members of one's profession
    4. Staff
    5. Staff and families
    1. Apathy
    2. Diligence
    3. Respect
    4. Resilience
    5. Communication skills
    1. Frequent but varied eye contact
    2. Aggressive posture
    3. Assuming a different posture from the patient
    4. Crossing arms
    5. Speaking in a loud voice
    1. Distance, dismissive attitude, distraction
    2. Distance, empathetic attitude, distraction
    3. Distance, empathetic attitude, focus
    4. Distance, dismissive attitude, focus
    5. Closeness, dismissive attitude, focus

    Author of lecture Therapeutic Relationship and Communication with Patients

     Mark Hughes, MD, MA

    Mark Hughes, MD, MA

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