Published online ahead of the July/August 2021 issue of FPM on June 21, 2021.
COVID-19 introduced several barriers to effective doctor-patient communication. Personal protective equipment (PPE) complicated our ability to read and understand one another's nonverbal cues, and often made verbal communication more difficult as well. Physical distancing and isolation removed the role of physical touch from patient visits and kept families apart during times of illness. And telehealth further complicated doctor-patient interactions. Each of these barriers were necessary to slow the spread of disease, but they contributed to fatigue, poor attitudes, and poor communication.
While our communities are beginning to open up, and our fear of getting the virus has lessened as more individuals have gotten vaccinated, we likely still face months of continued safety measures. For example, although many practices no longer require physicians to wear face shields, they do still require face masks.
As COVID-19 fatigue has grown, physicians and their staff members may have become lax in employing good communication strategies — such as “smiling with our eyes” behind the masks. We may not be trying as hard any more to make personal connections. Therefore, it is a good time to check in on how we are communicating with our patients and how we can reestablish rapport.
COVID-19 safety measures and COVID fatigue have made doctor-patient communication more difficult.
Effective verbal and nonverbal communication helps patients feel safe, which allows them to share more comfortably the physical and emotional aspects of their illness.
Even with face masks, physical distancing, and telehealth, physicians can take simple steps to improve their communication and deepen their connections with patients.
WHY COMPASSIONATE COMMUNICATION MATTERS
Research makes clear that compassionate caring as manifested in therapeutic communication techniques is essential for patient care and for our own well-being.1 Therapeutic communication techniques help the clinician establish effective, patient-centered interactions and have a wide variety of effects on patient care, such as improving patient adherence, lowering the chances of malpractice claims, increasing the number of favorable medical outcomes, increasing patient satisfaction, and improving efficiency. The more effectively a clinician communicates verbally and nonverbally, the more likely patients are to feel safe, which in turn allows them to share more comfortably the physical and emotional aspects of their illness. In response, the clinician can properly formulate a diagnosis and prepare a treatment plan that will better match the needs of the patient. There is also increasing evidence that the experience of providing compassionate and emotionally connected care to patients is a buffer against clinician burnout and a source of resilience and fulfillment.1
Patients can detect whether we are genuinely emotionally present with them. Research has found that patients may excuse bad bedside manner to some degree if they sense that we are being authentic.2 Authentic caring signals to the patient that we will be there no matter what, and that gives the patient confidence in the relationship.2 Authentic caring comes through even when our communication skills are not polished, and even through all our PPE. A compassion mindset animates our technical abilities and our motivation to help the person in front of us, even if time is short and the patient cannot see our face fully.1 Our medical care is better when we are compassionately motivated, and it shows in our communication.
Research on the neuroscience of compassion has discovered the process of neuroception, which means that human beings have a rapid, unconscious neural ability to assess safety, stress, or mortal danger in any interaction. Using this idea, Porges discovered the Polyvagal Theory, in which humans (and mammals in general) have the ability to assess safety based on facial, vocal, and nonverbal cues.3 A person feels safe by perceiving one or more of the following signals: warm and familiar faces, expressive emotions, eye contact, the lifting of eyelids or crinkling at the eyes, familiar voices, and listening behavior.1 When a clinician is virtual, distant, or wearing PPE, many of the facial nonverbals become difficult for the patient to detect, which can lead the patient to feel unsafe. Confirming this idea, studies show that face masks have a significantly negative effect on the patient's perception of physician empathy.4
CONVEYING CARE BEHIND A MASK
UMass Memorial Medical Center found a way to ensure proper PPE and make patients feel safe by using portraits to humanize PPE. The medical center's staff and clinicians attached small photographs of themselves displaying some nonverbal cues, such as smiling or eye crinkling, to the front of their PPE so that patients could see their faces. While this intervention seems simple, one survey showed overall positive results, as PPE portraits improved the mood of 79% of patients and made them smile.5
Clinicians can also improve communication with patients by emphasizing nonverbals that are not hidden behind PPE, such as hand gestures, posture, head nodding, eye contact, and even physical position within the exam room.6 Additionally, the lack of nonverbal communication increases the importance of verbal communication. Verbally validating patient emotions and building rapport throughout the patient interaction are ways to overcome nonverbal communication challenges presented by PPE and make the patient feel safe.7 Speaking slowly and distinctly, enunciating, and facing patients when talking to them with a face mask on ensures they can hear your empathic verbal communication.
Even though some facial expressions are less visible behind a mask, clinicians should not make the mistake of considering these expressions to be less important. For example, smiling is communicated not only by the mouth and lips, but also by the crinkling of the skin around the eyes and the tone of voice. It is crucial that clinicians maintain their expressiveness — or even exaggerate it — because of the secondary ways patients can pick up on facial nonverbals. If clinicians believe that their own facial and nonverbal behaviors do not matter because of PPE, they run the risk of being perceived as more detached, because their flattened affect will be apparent in subtle vocal and behavioral cues. While clinicians may know this, COVID-19 fatigue and continual mask-wearing can lull them into forgetting these simple facts about facial expressions and good communication.
COMPENSATING FOR PHYSICAL DISTANCING DURING SERIOUS MEDICAL CONVERSATIONS
Serious conversations have been especially difficult during the pandemic. Telling patients that they might have a serious illness is always hard to do, but even more so with masks and distancing. Typically, in a serious medical conversation, the clinician leans in and uses physical touch to communicate care for the patient, who is in a state of emotional and physical vulnerability. Often, the patient's loved ones are there to console and comfort as well. The vulnerability of the moment is addressed through relevant empathic touch and familial support. But in light of physical distancing, these aspects of breaking bad news are lost, as clinicians must keep their distance, and the patient's loved ones are either discouraged or prohibited from being in the room. The patient is left vulnerable in the presence of the physically distanced clinician, amplifying the isolating effects of the moment.
To compensate for physical distancing, clinicians must find other ways to achieve emotional closeness with their patients during these conversations. Carefully chosen verbal communication coupled with good listening skills help give patients the sense that they are cared for. Two acronyms have also proved helpful in achieving this expression of compassion:
SPIKES stands for setting up the appointment meaningfully, checking patient perception of bad news, inviting the patient to ask questions, having knowledge of medical facts, exploring and responding to emotions, and establishing a strategy for support.8
CALMER is an acronym developed specifically for patients who are seriously ill due to COVID-19, but could be repurposed for any serious illness. It stands for checking in with the patient, asking about COVID-19 and the patient's situation, laying out the possible complications that could arise in the patient's health, motivating the patient to choose a proxy should the illness take a turn for the worse, expecting and acknowledging patient emotion, and recording the patient's responses in the chart.9
Additionally, physicians can use the physical exam as an opportunity to integrate physical touch into the medical interview. For example, when listening to the patient's heart, the clinician might place a hand on the patient's shoulder. Physical touch can deepen the patient-clinician relationship10 because it is positively realized in multiple physiological systems, serving as a highly effective indicator of connection.11
Being open and honest with the patient about COVID-19 precautions can also be helpful. For example, the physician might say, “I'm sorry we have to have these masks on and your loved ones aren't in the room, but I care about you and want to know how you are processing this.” The clinician might also want to invite the patient to call or videoconference a friend or family member into the conversation, or the clinician could take notes or give fact sheets to the patient to share with loved ones after the appointment.
Checking in with all parties to make sure they understand the diagnosis, treatment, and next steps of the patient's illness is vital. Silence by patients or their family members, which is often mistaken for understanding, should be addressed to make sure it doesn't stem from a sense of confusion. It is imperative to surround the patient with as much support as possible when sharing life-changing information and to equip all parties with the necessary information to ensure understanding.
COMMUNICATING EFFECTIVELY DURING TELEHEALTH VISITS
Telehealth has become widespread during the COVID-19 pandemic, as it minimizes the risk of face-to-face contact between the patient and clinician, preventing the spread of the disease. However, telehealth also brings challenges to patient-clinician communication.
It is difficult to make eye contact during a video visit because you are not usually looking into the camera but at the computer screen, either to view the patient or the chart. In addition, small facial expressions can be difficult to detect on a computer or other device (depending on the quality of the technology used for communication), and body language and hand motions usually do not appear on screen. Background noise, distractions, and technical difficulties frequently interrupt conversations between the patient and clinician as well. The hindrance of communication skills in telemedicine can be detrimental to the patient's feelings of safety and ability to socially engage.
Several practical techniques can improve communication during telehealth visits. First, make sure that lighting in the room does not cast shadows on your face, and be aware of camera placement so that you can provide eye contact. Some telehealth programs allow you to move the patient video around the screen so that it is adjacent to the camera lens. Additionally, an external camera can be mounted to the computer to show more direct eye contact. Having the volume set at a proper level and noise-proofing walls ensures that verbal communication is clear and confidential. Prepare such conditions in advance, and if you cannot see or hear a patient properly, convey this to the patient immediately. You and your patient should feel comfortable communicating about the conditions of the video call.
Other tips include closing the blinds to ensure privacy and asking the patient to meet at a time when there will be fewer distractions (e.g., when the patient's kids are at school or spouse is at work).12 You might find it beneficial to create a dedicated space for telehealth visits. In this way, you can ensure adequate conditions (e.g., lighting, sound, and technological set-up) before meeting with patients.
Beyond the meeting setup, be cognizant of “digital empathy,” that is, the expression of understanding and compassion while using technology.13 Increased awareness of a patient's uncertainties, worries, and fears are vital to the proper functioning of telemedicine. For clinicians, this increased awareness can be as simple as asking patients how they are coping with their illness and then working through their responses together. Additionally, you can actively listen to the patient, let the patient guide the conversation, follow up on the appointment via email or text message to let the patient know you are actively working on the case, and tailor interactions based on the patient's personality (e.g., a patient who tends to be health conscious versus a patient who tends to neglect personal health).14 You can also use a “virtual handshake” in your telemedicine protocol. This includes preparing and confirming patient details before the appointment, introducing yourself to the patient, summarizing treatment plans, and allowing the patient to ask questions or clarify any issues.15
CHECK YOUR ATTITUDE
Behind the face mask, the physical distancing, and the telehealth consultation is the attitude of the clinician. Good or bad, your attitude will carry through into your actions, words, and expressions. At the core of overcoming the communication barriers presented by COVID-19 is the desire to provide compassionate care to patients. Front-line workers must make every effort to show patients they care. Every intentional step you take toward better communication during this unprecedented time can make all the difference in the physical, emotional, and psychological well-being of your patients.