Case Scenario

A 48-year-old patient presented with a history of major depressive disorder and mildly elevated blood pressure. After two separate blood pressure measurements of 155/90 mm Hg, the patient's physician prescribed daily hydrochlorothiazide (HCTZ) to lower blood pressure. The patient asked if there was anything important to know about the medication, and the physician said the patient should eat a banana daily to keep potassium levels up. The patient was advised to follow up in the future. The physician did not ask about any other medications the patient was taking or other health habits, and additional blood tests were not ordered.

The patient was taking escitalopram (Lexapro), which a psychiatrist prescribed, was an avid runner, and often fasted one day per week for health reasons. The patient took the HCTZ as prescribed and, over the next few weeks, began to feel weak and dizzy. The patient called his physician, who diagnosed acute labyrinthitis over the phone and prescribed meclizine for vertigo. The patient's symptoms worsened despite the new medication, and the patient passed out during a run one week later, on a day of fasting. At the emergency department, the patient's blood pressure was 75/50 mm Hg, potassium was 2.3 mEq per L (2.30 mmol per L), and sodium was 117 mEq per L (117.00 mmol per L). The patient was admitted to the hospital, and the HCTZ was immediately discontinued.

Clinical Commentary

Good communication between physicians and patients is essential to enable good outcomes and avoid medical errors. Sometimes patients cannot express their concerns and needs clearly. Conversely, physicians often overestimate their communication skills, and such skills have been shown to decline during a physician's career.¹ Breakdown in communication can lead to harm and suboptimal treatment. A previous article in American Family Physician highlighted the importance of involving the patient as a partner in the diagnostic process,² something that can only occur with good physician-patient discourse.

Poor communication can lead to a medical error when a patient does not report their allergies or health history to a physician, or when a physician does not correctly or thoroughly record a medical history or medication list, as in this patient's case. When clinicians do not communicate well with each other, errors can occur because of incorrect or missing information.³ But harm may also occur when patients do not follow a prescribed course of care or physicians do not inform patients of potential risks of treatment.

Studies have shown that ineffective clinician communication can reduce patient adherence to care. One study found that when patients believed communication was optimal, 70% followed recommendations, whereas when communication was deemed poor quality, only 50% did. Patients with lower adherence had worse outcomes and a substantially higher cost of care.⁴ In 71% of cases in which patients did not follow a physician's care plan, they did not agree with what the physician recommended, or they did not fully understand the physician's instructions. This can occur when a physician does not explain the recommendations adequately and does not allow patients to ask questions or voice their beliefs or concerns.⁵ When patients are allowed to tell their story and physicians explain information in a way that patients understand, adherence and quality of care improve without increasing the patient visit time.⁶ Good communication has been associated with higher patient satisfaction, increased adherence to therapy, better control of blood glucose and blood pressure, fewer medical mistakes, and increased symptom resolution.⁷

What constitutes effective physician-patient communication? Often it is spending time listening to a patient's needs and wants and understanding each patient's circumstances. A short discussion of the patient's health habits would have impacted medication choice for this patient. Studies suggest that listening, explaining, and having empathy are the three most important factors in increasing patient satisfaction and outcome.⁵ Studies show that poor communication leads to a poor sense of physical and mental health compared with more optimal communication.⁴ When physicians do not sufficiently explain interventions, do not respect the health beliefs of their patients, and do not try to reach consensus, the likelihood of therapeutic failure and error increases.

Poor communication can lead to a nocebo response, in which patients feel they are not being heard, do not convey all their health information to the physician, and tend to ignore advice.⁸ For this patient, the physician's limited questioning created a breach where the patient did not convey important information to the physician and impeded the physician from recognizing symptoms that were caused by a medication the physician prescribed.