Q&A: Improving patient–doctor communication

When patients don't feel heard by their doctors, there's an erosion of trust that can lead to serious health consequences—even if clinicians have their patients' best interests in mind.

Mary Catherine Beach, MD, MPH, a professor in the Department of Health, Behavior and Society and at the Johns Hopkins School of Medicine, studies patient-provider communications. In an episode of Public Health On Call, she talks about what can happen when patients don't feel heard, ways to teach providers better communication skills, and how biases can come into play.

How can you tell if your health care provider is listening to you?

As a patient, you're looking for your doctor to show you that they have heard what you said and they understand it. That might mean that you're looking at them while you're talking, and the physician is looking back at you, nodding, or making eye contact. Or they're reflecting back what you said by paraphrasing you or asking questions that are relevant to what you shared.

If someone feels like their doctor isn't listening, what options do they have?

There are a couple of options. The first is to say something like, "I want to make sure that I've been totally clear, because my main concern is (state the main concern)" or "I have a couple of questions that I really need answers to." By doing this, the patient can make clear that they actually need to pause and get some sort of positive response. It is possible that a physician is not showing you that they're listening, but they are indeed taking in what you're saying.

If you find yourself having to do that repeatedly, and a practitioner is still not listening to you, you should be looking for a new provider if possible.

That seems like a pretty big burden to put on the patient.

I spend most of my time trying to improve the way health professionals communicate. That includes things like proactively showing patients that they're listening, explaining things in a way that the average person can understand, not giving long lectures using big words. I also encourage them to ask patients what they would like to hear or what questions they have before launching into long explanations. These are all ways to get patients more engaged, because as a patient, if you're talking more, you're going to remember more.

I do think that the burden should be on the health professionals to do this well, but there are so many challenges. So in absence of that, it's also important to empower patients to get what they need.

This role of the provider-patient relationship in health care is really fundamental to being healthy people, isn't it?

It totally is. If you don't feel like you can trust your health care provider—that they're not listening to you or not competent—or if you aren't 100% certain they have your best interests at heart, you may not feel confident in following their advice. Our research has shown that people who feel they don't have a good relationship with their doctor are a lot less likely to take lifesaving medications.

How have you worked with providers to improve the ways they interact and build relationships with patients?

We've done a couple of interventions where we have met with clinicians and reviewed common provider-patient conversations. For example, we worked with clinicians on how to talk more effectively with patients about adherence to medications.

Typically if a patient says they're not taking medication, the clinician tends to jump in and explain why that's bad and why they need to take their medications. We encouraged them to instead step back and ask questions to understand what's motivating the patient's decision to not take medication: What are their thoughts on the medications? Do they feel medications are a good idea? Do they feel it's important to take the medications?

This pulls from the field of motivational interviewing, which involves learning from people what they think is important and what they're willing to do. And because the communication techniques in motivational interviewing are so different from what we're typically taught as physicians, that can be really groundbreaking in showing physicians a different, better way to communicate. Physicians are actually very motivated to change how they talk to patients so that they can be more effective.

What about working with patients to change how they approach these interactions?

I haven't personally done a lot of work with activating patients. There have been studies that tried to work with patients in waiting rooms, to get them to write down their questions or write down the specific issues they want to talk to their physician about. But I don't think there's been as much work there. And that's mainly because it feels like a lot of pressure to put on patients.

The patient-provider relationship obviously is key to a person's health care experience. Do certain patient populations tend to face more issues in building that trusting relationship?

Yes, there is substantial research looking at how communication differs by patient race and some by patient gender. Unfortunately, the studies show that doctors tend to talk a lot more relative to Black patients compared to white patients. The term that we use for that in communication research is "verbal dominance."

Related to whether patients feel listened to is the phenomenon of whether a doctor takes seriously what a patient tells them. We've done studies that show that Black patients feel like their concerns are dismissed a lot more than white patients. We've also looked at the language doctors use in patient medical records that might indicate whether they believe a patient, and that research showed more indications in the records of Black patients that a physician doubted what the patient said.

How do other personal biases play into patient care and potential barriers to accessing care?

Like any person, providers will sometimes have opinions about how to live a good life and what people should or shouldn't do. Personality research has shown that some people are naturally more dogmatic and judgmental of others. Doctors are just like anybody else. And if they're judgmental of somebody's choices, that's going to be conveyed in how they communicate with the person.

We're empowered as doctors to feel like we have all this medical knowledge, so we get excited at the idea that we can help with a particular treatment. And if somebody decides they don't want that treatment, a lot of times doctors will get frustrated, and sometimes that's because they really care. That frustration doesn't all come from a bad place, but it doesn't make the patient feel respected when a doctor judges their choices.