Communication in health care: easy to learn, difficult to apply

In her inaugural speech at the Radboud University Nijmegen (September 28^th, 2012), Sandra van Dulmen stressed the importance of looking beyond the well-known paths of education and training and of unravelling multi-layered context factors that hamper or facilitate improvements in the way health care providers and patients communicate.

Nowadays, patient responsibility, participation and self-management are supposed to lift up health care like magic words creating a miracle. Patients are considered to be active contributors to interactions with their health care providers in the consulting room and are expected to share decision-making leading to optimal care adapted to a patient’s lifestyle and capabilities. Patients are thought to be perfectly capable of pointing out what they need as they are supposed to be well-informed and assertive. Yet, everyday practice shows a quite different picture; during the last decades, patients have not asked more questions to their health care provider, on the contrary, they now seem even less assertive than 25 years ago, at least when observing their behaviour in the consulting room. Maybe, being assertive and being sick do not go together? Patients do particularly value the way health care providers engage with them and the majority wants to be informed in a clear way.

Yet, Dutch studies show that health care providers themselves seem less convinced of the value of good communication and many residents even believe that they spend too much time on communication training. Important observations, especially when one notices that what providers are being taught does not always become visible in their actual communication behaviour. Apparently, the context in which a provider has to act differs so much from a training situation that there is no guarentee that what is trained will be implemented. Factors that determine this so-called transfer from what is taught to its application in daily practice, do not yet receive much attention in research in communication in health care. Despite this lack of evidence, a lot of time, money and energy is being put in training providers without first identifying factors, like health care system characteristics, that hamper proper implementation.

Unraveling the multi-layered context factors that hamper or facilitate improvements in the way health care providers and patients communicate could for instance indicate why many patients feel more comfortable talking to nurses about sensitive issues than to physicians, why patients fall silent when they enter the consulting room, why residents’ communication skills do not seem to improve despite so many efforts to teach them the necessary skills. What is more, being taught generic communication skills and having to use these within a specific interaction with an individual patient, does not appear to be easy. Person-centered communication, i.e. providing support and information adapted to what a person already knows, what he needs and values, what he understands and expects, what comforts, reassures and empowers him, is a real challenge.

For some patients, a group medical visit is the right context to educate and engage them, others feel more comfortable within a face-to-face or an online, screen-to-screen contact. Communication helps to find out what suits a patient best. Therefore it is important to keep cherishing the quality of the encounter, also between health professionals, and to invest in an understanding between providers and patients. Because, as long as most complaints from patients have to do with communication and the way they are being treated, we have work to do. To do this properly, every stakeholder has to do his part: the patient, the health care provider, the policy maker as well as the health care insurer.

Sandra van Dulmen is Programme coordinator Communication in healthcare at NIVEL Utrecht, Professor at UMC St Radboud, Nijmegen and Professor at Buskerud University College, Drammen, Norway