Patient Communication & Interpersonal Skills

Opening the interview and responding to emotion

Start open, then stop talking. Begin with a broad, open-ended question ("What brings you in today?") and let the patient speak; physicians interrupt, on average, within about 11 to 18 seconds. Elicit the full agenda first ("Is there anything else?"), then narrow to closed questions to characterize each problem. Leading questions ("You're here for diabetes, right?") and early closed questions ("Do you have chest pain?") are poor openers.

NURSE. Respond to emotion before delivering more information. Empathic statements build the therapeutic alliance and improve adherence.

• Name: "You seem frightened."
• Understand: "I can see why this feels overwhelming."
• Respect: "You've handled a lot."
• Support: "We'll face this together."
• Explore: "Tell me more."

Naming the emotion aloud is the highest-yield empathic move. It acknowledges the feeling without agreeing with it, and it is usually the best next statement when a patient becomes tearful, frightened, or upset.

The angry patient. Stay calm and non-defensive, sit down, listen, and name and validate the emotion ("I can see you're frustrated; help me understand"). Do not argue or justify; acknowledging a genuine problem, such as a long wait, and apologizing for the experience defuses more than defending does. Set firm limits only on abusive or threatening behavior.

Delivering bad news: SPIKES

Never in a hallway. Bad news is delivered stepwise, and the order matters: find out what the patient knows and wants to know before telling.

Perception and Invitation always precede Knowledge. After ensuring privacy, the best next step is to ask what the patient already understands, not to quote survival statistics or recommend treatment.

When family members ask you to withhold a diagnosis, explore their concerns, but the patient decides how much to hear. A patient with capacity who wants to know should be told.

Behavior change: motivational interviewing and stages of change

Motivational interviewing (MI) is collaborative and nonjudgmental. Its skills are OARS: Open questions, Affirmations, Reflective listening, and Summaries. Its principles are to express empathy, roll with resistance, develop discrepancy between current behavior and the patient's goals, and support self-efficacy. The aim is to elicit the patient's own change talk; ask permission before sharing information.

Avoid the righting reflex (lecturing, warning, or arguing for change). It triggers resistance. The patient, not the clinician, should voice the arguments for change.

Making the message land: literacy, language, and culture

Teach-back. Ask the patient to restate the plan in their own words ("To be sure I explained it well, tell me how you'll take this") instead of asking "Do you understand?", which invites a reflexive yes. Teach-back closes the loop on comprehension and is essential for low health literacy.

Plain words and absolute risk. Roughly one third of US adults have limited health literacy. Avoid jargon, use plain language and visual aids, and express risk as absolute numbers and natural frequencies ("About 3 in 100 people get this side effect") rather than relative risk, hazard ratios, bare percentages, or statistical significance.

Interpreters. For patients with limited English proficiency, use a professional or certified medical interpreter (in person, by phone, or by video), not family members, and never children, especially for consent. Address the patient directly, in the first person, and look at the patient rather than the interpreter. Ad hoc interpreters raise error rates and breach confidentiality.

Cultural humility. Rather than "mastering" cultures as fixed facts (cultural competence), cultural humility means lifelong self-reflection, recognizing power imbalances, and treating the patient as the expert on their own culture. Ask about beliefs and preferences and avoid stereotyping. The LEARN model (Listen, Explain, Acknowledge, Recommend, Negotiate) and teach-back help bridge cultural and language gaps.

Consent, shared decisions, and disclosing errors

Informed consent has three requirements:

• Capacity: the patient can understand the information, appreciate how it applies to them, reason through the options, and communicate a choice. Capacity is decision-specific and assessed clinically; competence is a legal determination made by a court.
• Disclosure: the diagnosis, the proposed procedure, its risks and benefits, and the alternatives, including no treatment. Many states use the "reasonable person" materiality standard: disclose what a reasonable patient would want to know.
• Voluntariness: the decision is free of coercion.

Exceptions to consent. Emergency (implied consent), patient waiver, and lack of capacity (a surrogate decides). A notarized signature, family approval, or a second physician's signature is not required.

Shared decision-making fits preference-sensitive choices with several reasonable options, such as PSA screening or anticoagulation. Present the options and their trade-offs, elicit the patient's values, and decide together. It differs from basic consent by explicitly weighting the patient's values.

Disclosing errors. Disclosing a harmful error promptly and directly is an ethical duty.

Disclose even when the patient recovers fully. Do not wait to see if harm develops, leave the decision to risk management, rely on an incident report alone, or blame others.