Relationship-centered Care and Clinical Dialogue: Toward New Forms of "Care-Full" Communication

Doctor-patient communication can significantly improve many clin­ical outcomes, including ensuring diagnostic accuracy, enhancing patient satisfaction, improving compliance, and reducing malprac­tice cases, which can potentially transform clinical relationships into more collaborative encounters.^1,2 Yet recent studies on participation in clinical interaction show it’s not just the amount of communica­tion, but the kind of communication that leads patients to perceive superior quality of care. An interesting set of questions now emerges: What is the relationship between care and communication? How do different models of communication transform care? And how do different models of care transform communication?

 

Traditionally, medical care has relied on a top-down, sender-receiver model of communication, often described as paternalistic or physician-centric care.³ Recent moves toward patient-centric care and patient autonomy recognize the importance of listening to the voices, values, and opinions of the patient. The more integrative, long term–focused, relationship-centered care model now gaining ascendance with its companion “participatory medicine” has the potential to shift health­care and clinical practice toward more doctor-patient dialogue.^4,5

 

At its core, relationship-centered care is characterized by a part­nering approach with patients that includes shared decision making featuring 4 underlying principles:^6,7

 

Elias Zerhouni, MD, former director of the National Institutes of Health, predicts a major shift in doctor-patient communication. “The future is going to be patient-centric and proactive. It must be based on education and communication. . . .It requires voluntary, intelligent participation, not passive acceptance. We can provide the information, but you [the patient] have to do some­thing for yourself.”⁸ How can healthcare practitioners play a role?

 

By definition, dialogue requires at least 2 voices. Philosopher Martin Buber presented a theory of dialogue as being much more than the exchange of messages and talk that takes place in human interaction.⁹ For Buber, dialogue is relational and responsive. Even more, Buber argues that dialogue is an essential building block of community. His philosophy of dialogue depends on how the self interprets the other, or “thou.” Buber is not suggesting by “thou-ness” that every relationship should move toward intimacy and the disclosure/realization of the other’s real self but that the “realness” of the other resists fixation or a closure of conversation.¹⁰ Every interaction holds the possibility of closure or new meaning. Dialogue is a process by which patients and physicians engage differently and in so doing make communication productive, creating some­thing new together, as opposed to reproducing what either one has or is.

 

When we take this perspective and couple it with reciprocal influence, we begin to engage what Ronald M. Epstein, MD, whose teaching and research focuses on communication in clinical settings and the patient-physician relationship, describes as a multidirectional model of commu­nication.¹¹ Such a model of communication requires us to consider this question: Is clinical care about information quality/quantity or is it about understanding how and when we should share information with our clinical partners, both in relation to when they ask for it and when we might think they may benefit from knowing what we know?¹² As Street, et al, found, more assertive patients who ask more questions seem to elicit more part­nering statements from their physicians, moving from a one-way form of information transmission to a true interaction.¹³ So what kinds of commu­nicative practices do we need in this clinical frame?

 

When we focus on the fact that every message and person is impor­tant, we are more open and receptive to ideas. When taking notes, we can shift our mindset toward patient-centered care by writing down everything we hear instead of what we assess as most important in the moment.¹⁴ We can also learn from our patient’s nonverbal communica­tion: How does the patient’s physical body respond to what is being said? Note any signs of agitation, distress, or withdrawal that may manifest as shifts in posture, eye gazes, pauses, and silences.

 

Second, ask artful questions at the appropriate time to engage in a sharing of perspective and knowledge.¹⁵ The artful question may be “Tell me about a day in your life,” or “How’s the garden going these days?” The artful question is contextually and clinically related. It can help build relationships and paint a holistic picture of the situation in which care is being performed and health is impacted.

 

Finally, consider future “care-full” interactions and build bridges while working with boundaries. Not all information-sharing has to happen in the 7 minutes allocated to the appointment. Instead, consider how rela­tionships develop beyond that brief period. As Buller et al point out, a trusting relationship enables the patient to tell his or her story and share concerns to help prevent misunderstanding and conflict while simul­taneously promoting patient and physician satisfaction.¹⁶ One retired physician expressed this as “walking into suffering and walking through it together empathically,” recognizing and realizing the multifaceted nature of the clinical journey.^17,18

 

Central to this relational development are the practices of reflective listening, employing statements such as, “What I am hearing you say is. . ,” “Does this seem right to you?” and “Have we missed anything?” Also important are partnering statements such as, “How would you like us to proceed?” and “When can we meet again?” Interestingly, as Young et al found in several studies, a very minor action by patients stimulates a little more sharing of decisions by physicians.^19,20,21 Even practices such as recompleters (finishing someone’s statement for them), often inter­preted as interrupting, can facilitate discussions by making explicit your understanding and acknowledgment of the other person’s message prior to responding. In so doing, each participant is affirmed as valued and meanings are clarified.²²

 

 

 

If reciprocity is indeed a norm we desire, then physicians may wish to share equally, which includes some sort of physician self-disclosure to keep the conversation going beyond two sentence exchanges. However, as Morse et al discuss, self-disclosure historically has been considered inappropriate in clinical practice.²³ Ultimately, the only appropriate purpose of physician self-disclosure is to serve patient needs as a form of role modeling or as a means to build relationships, promote intimacy and mutuality, and, in some cases, decrease hierarchy.¹⁷ Interestingly, physician responses to patient requests for self-disclosure can create ease in this long-term relationship and are especially powerful as they can easily be turned back to focus on the patient.

 

All healthcare is intensely personal.²⁵ One of the legacies of a physician-centric form of care is the impoverished patient or clinical partner. The move to a participatory, relational form of care requires the recovering and revitalizing of this partner, in many ways through a notion of self-care. Patients need to become empowered to be more responsible for their own health and more knowledgeable of what health means on their own terms and in their own lives.²⁶ Healthcare providers can help facilitate this process.

 

There are times when conversation is difficult—even impossible. We cannot underestimate the need for and influence of “attachment figures” in difficult care situations.²⁷ Attachment figures are respected, trusted, and expert in the care of their partners. They perform this role through their commitments to being attentive, curious, flexible, and present.