In heart failure, as in probably all chronic disease, effective support is based on continuity of care backed by education of the patient, who is encouraged to participate in managing his or her illness. Skill and patience are required on both sides, particularly in situations that make severe demands on patients’ powers of concentration (eg, gross polymedication) or perseverance (as when adjusting the dose of an angiotensin-converting enzyme [ACE] inhibitor or (3-receptor blocker, or embarking on a long-term exercise program or other seemingly sacrificial lifestyle changes). Other instances include encouraging patients to perform self-monitoring tasks, such as recognizing certain symptoms and/or measuring their weight daily, and adjusting their dose of medication (eg, diuretic) accordingly. Patients also need help in learning to decide whether to go for an outpatient visit or to simply call their doctor for advice.
The purpose of this co-optive strategy is more to improve quality of life, with its related health benefits, than to improve treatment itself. A chronic disease, after all, will tend to follow its natural course. We thus ask much from our patients, but we do so in the knowledge that two-way exchange is a therapy, albeit nonpharmacologic, in its own right. Together with an appropriate organizational structure, patient-physi-cian communication is integral to effective treatment.
Thomas Szasz and Marc Hollender, in 1956, made one of the first scientific contributions to the analysis of doctor-patient communication, suggesting that the adult/adult model of mutual participation, in which the doctor helps the patient to help him- or herself, be applied to the clinical management of chronic disease. In 1992, in the United States, the Emanuels (EJ and LL) produced a 4-model typology of the patient-physician relationship, while Bruno Bara in Italy redescribed dialogue as a cognitive process. Cooperation between two partners clearly calls for greater motivation and higher intention than when only one person is involved. The interpretative and collaborative models enhance relationship stability, which is important when treating a chronic disease such as heart failure. Yet physicians should still learn to modulate their communication style to the patient’s cultural and emotional background and disease stage, while concentrating on as collaborative an approach as possible, discarding those models that prevent patients from expressing their needs.
Roter et al compared the Emanuels’ ideal behavioral models with the audiotaped communication patterns in 537 patient visits to 127 physicians. The narrowly biomedical‚ pattern, characterized by closed-ended medical questions and biomedical talk by the physician, was frequent (32% of visits) and embodied the key features of the paternalist model: absent patient viewpoint, minimum psychosocial exchange, patient nonparticipation in communication, and an interview guided and directed by the physician. The con-sumerist‚ pattern was characterized by patient questions and physician information giving; it was rare (8% of visits), and resembled the informative model. In the expanded biomedical‚ and biopsychosocial‚ patterns, which were frequent (33% and 20% of interviews, respectively), discussion steadily increased until a psychosocial dialogue ensued. The psychosocial‚ pattern itself (8% of visits only) featured questions other than the purely medical, and resembled both the interpretative and collaborative Emanuel models. Patients’ values were examined and negotiated in these interactive exchanges, which gave the patient opportunities for leadership. In their analysis, Roter et al showed the strength of the paternalist model and the little use made of the collaborative model in daily medical practice.
The collaborative model requires time in which to talk to the patient and plan appropriate supportive measures. This is rarely available in the outpatient clinic. However, from the physician, it also calls for active listening, acute observation, and empathy with the patient’s values, capped by communication skills which are not simply instinctive or derived from experience, but can also be taught and learned. Since communication is, by definition, a two-way process, teaching has positive effects on not only medical staff, but also the patient. In a recent study on the effects of teaching communication, patients were issued with printed instructions on how to ask for information and check that the answers were appropriate. This was sufficient to enhance their adherence to lifestyle recommendations (diet, exercise, cessation of smoking), and punctuality of follow-up.
Physicians must always remember that patients are often subject to mood disturbances (due to anxiety, depression, phobia, negation or minimization of their illness, etc) and cognitive lapses, with respect in particular to short-term verbal memory. These impair not only their adherence to treatment, but also their ability to engage in effective communication. Awareness of this fact should prompt appropriate strategies on the part of the
management; communication; counseling; organization; patient-physician communication; strategy; psychosocial interaction, motivation